(Government Code § 910, 910.2)
INSTRUCTIONS (Please read carefully):
Claims related to injury to person or damage to
sonal property must be presented to the City
within six (6) months from the date of loss.
Claims related to any other loss must be presented
later than one (1) year from the date of loss.
Answer all items fully and to the best of your
knowledge and information. Failure to do so may
result in your claim being found insufficient. If more
space is needed to provide requested information,
please attach additional pages identifying
agraphs(s) being answered. Please click in t
rey text fields to type requested information.
Date/Time Received by the City Clerk
[City Use Only]
Pursuant to Government Code § 915a, please file your claim with the City Clerk.
TO: City Clerk
City of Diamond Bar
21810 Copley Drive
Diamond Bar, CA 91765
1. Claimant's Name:
rimary Phone Number: Claimant’s Date of Birth:
2. C
laimant's Mailing Address:
Street Number Street - Apt No. City State Zip
3. Da
te/Time of Loss:
4. Location of Loss (Specify in as much detail as possible)
Description of incident/accident that caused you to make this claim:
6. What specific injury, damages or other losses did you incur?
7. List damages incurred to date. (Attach copies of receipts, repair estimates, bills, invoices and any other
documentation to prove your loss.)
8. What are your total estimated prospective damages?
9. What is your basis for claiming that the City or City employee(s) are the cause of your injury, damages or
10. What are the name(s) of the City employee(s) whom you allege caused your injury, damages or loss, if
11. Name, address and phone number of any witnesses who can substantiate your claim:
12. Any additional information that you believe might be helpful to the City in considering this claim:
13. All notices and communications with regard to this claim will be directed to the Claimant shown in lines 1
and 2 above unless you complete the following to identify to whom further communication should be
Mailing Address:
Street Number Street - Apt No. City State Zip
Primary Phone Number:
For all accident claims, place on following diagram names of streets, including North, East, south, and West;
indicate place of accident by "X" and by showing house numbers or distances to street corners. If City vehicle
was involved, designate by letter "A" location of City Vehicle when you first saw it, and by "B" location of
yourself or your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and
location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X". NOTE: If
diagrams below do not fit the situation, attach hereto a proper diagram signed by claimant.
I/We, the undersigned, declare under penalty of perjury that I/we have read the foregoing claim for damages
and know the contents thereof; that the same is true of my/our own knowledge and belief, save and except as
to those matters wherein stated on information and belief, and as to them, I/we believe to be true.
Printed Name of Claimant or Person filing on their behalf: Date Signed:
Signature of Claimant or Person filing on their behalf
giving relationship to Claimant
WARNING: Penal Code Section 72 makes it a crime punishable by imprisonment to submit a “false or
fraudulent claim” for payment to a city or public district, and Code of Civil Procedures Section 1038
authorizes the award of attorney fees against a claimant who brings a claim that is “not brought in
good faith and with reasonable cause.”