FORM 10-04 REV 12/12
PAGE 1 of 2
CLAIM FOR DAMAGES
CITY CLERK'S OFFICE
INSTRUCTIONS:
File original claim with the City Clerk's Office, P.O. Box 19575, Irvine, CA 92623-9575. Failure to provide sufficient information
may result in delays in claim processing.
PLEASE NOTE:
1. Claims for death, injury to person or to personal property must be filed no later than six (6) months after
the occurrence (Government Code Section 911.2). This applies to occurrences after January 1, 1988.
2. Claims for damages to real property must be filed no later than one (1) year after the occurrence
(Government Code Section 911.2).
3. Review and complete entire Claim For Damages form before filing.
4. Attach separate sheets, if necessary, to give full details.
5. This form must be signed by the claimant or a person on his/her behalf (Government Code Section 911.2).
6. This form is for the convenience of those desiring to present claims against the City. Claimant is advised to
consult a private attorney if legal advice is desired. City employees may not give legal advice to any
claimant relating to private claims.
C L A I M I N F O R M A T I O N
LAST NAME OF CLAIMANT
FIRST NAME
MI
PHONE*
CITY
STATE
ZIP
IF CLAIMANT WOULD LIKE NOTICES SENT TO AN
ADDRESS DIFFERENT FROM ABOVE, INDICATE BELOW:
IF CLAIMANT IS REPRESENTED BY AN ATTORNEY,
PROVIDE NAME AND ADDRESS:
NAME
ADDRESS*
CITY
STATE
ZIP
NAME
ADDRESS
CITY
STATE
ZIP
DATE OF DAMAGE/INJURY
TIME OF DAMAGE/INJURY
AM
PM
LOCATION OF DAMAGE/INJURY (If known, include specific address and location)
Print Form
FORM 10-04 REV 12/12
PAGE 2 of 2
CLAIM FOR DAMAGES
DESCRIBE SPECIFIC NATURE OF DAMAGE/INJURY (Attach additional sheet if necessary)
SPECIFY HOW THE DAMAGE/INJURY OCCURED (Attach additional sheet if necessary)
NAME(S) OF CITY EMPLOYEES INVOLVED IN DAMAGE/INJURY/LOSS (If known)
SPECIFY WHAT PARTICULAR ACT/OMISSION ON THE PART OF CITY OFFICERS OR PUBLIC EMPLOYEES DO YOU CLAIM CAUSED
THE DAMAGE/INJURY (Attach additional sheet if necessary)
WERE POLICE ON SCENE?
NO
YES
WAS A POLICE REPORT FILED?
NO
YES
IF YES, PROVIDE POLICE REPORT NO.
GIVE THE AMOUNT CLAIMED AS OF THE DATE OF PRESENTATION OF THE CLAIM, INCLUDING THE ESTIMATED AMOUNT OF
ANY DAMAGE/INJURY/LOSS, INSOFAR AS IT MAY BE KNOWN AT THE TIME OF PRESENTATION OF THIS CLAIM, TOGETHER
WITH THE BASIS OF COMPUTATION OF THE AMOUNT CLAIMED, WITH ESTIMATES AND BILLS, IF APPROPRIATE. (Attach
additional sheet if necessary)
TOTAL AMOUNT
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE FACTS HEREINABOVE SET FORTH ARE TRUE AND CORRECT
TO THE BEST OF MY KNOWLEDGE.
SIGNATURE OF CLAIMAINT -OR- REPRESENTATIVE OF CLAIMANT
DATE
NOTICE: Section 72 of the Penal Code provides that: "Every person who, with intent to defraud, presents for allowance, or for payment to any state board or officer, or to any
County, Town, City, District, Ward, or Village Board or Officer, if genuine, and false, fraudulent claim, bill, account, voucher, or writing, is guilty of a felony."
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