(NOTE: It is a requi rement that this form, if used, be pre sented to and filed wi th the clerk o r secretary of the public e ntity
involved. This form i s bei ng provided as a courtesy to assi st you in f iling your claim. P roviding thi s form to you is not an
admission nor shall it be construed to be an admission of lia bility or a n acknowledgement of the validity o f a claim by the
political subdivision. Legal requirements for filin g claims can be found in Title 6, Chapter 9, Idaho Code. All claims must be
filed promptly, in writing!)
Name: Phone Number: (Home) (work)
Current Address:
Address for the Six Months Immediately Prior to the Date the Damage or Injury
Date Damage or Injury Occurred: Time: a.m. p.m.
on of Occurrence:
Any Injuries? Yes No If yes, what type?
Describe How Damage or Injury Occurred:
I hereby certify that I have read the above information and it is true and correct to the best of my knowledge.
I hereby make a claim against _______________________________________a public entity, for
_______________________________________(damage, injury, etc.) in the amount of ________________________.
If you were injured and you are on medicare/medicaid, please fill out the following as required by 42 U.S.C. 1395:
Date of Birth
Medicare/Medicaid number
(You may attach any other information or documentation you desire.)