Fill - Free fillable Form 5528: City Santa Barbara of Instructions for (City of Santa Barbara) PDF form

Administration

Tel:

(805)

564-5334

Accounting

Tel:

(805)

564

5528

Licenses & Perm its

Tel:

(805)

564-5346

Payroll

Tel:

(805)

564-5357

Risk Management

Tel:

(805)

564-5347

Fax:

(805)

897

2642

Treasury

Tel:

(805)

564-5340

Utility Billing

Tel:

(805)

564-5343

735

Anacapa

Stree

P.O.

Box

1990

Santa

Barbara,

93102

1990

Fax:

(805)

897

1978

Purchasing

Tel:

(805)

564-5349

Warehouse

Tel:

(805)

564

5354

Mailroom

Tel:

(805)

564-5360

310

Ortega

reet

P.O.

Box

1990

Santa

Barbara,

93102

1990

Fax:

(805)

897

1977

Environm

ental

Services

Tel:

(805)

564

5631

1221 Anacapa

Street

P.O.

Box

1990

Santa

Barbara,

93102

1990

Fax:

(805)

564

5688

City

Santa

Barbara

Finance

Department

SantaBarbar

aCA.gov

Instructions for filing a Claim for Damages

against the City of Santa Barbara

Any claim seeking monetary damages from the City of Santa Barbara must be submitted

on the City-produced claim form. The completed claim form must be delivered to the office

of the City Clerk as required by California law.

The completed claim form must be submitted with an original signature. Please include

any documentation of the damage claimed, include estimates, receipts and/or photographs

supporting the loss.

In general, a claim seeking damages from the City must be filed no later than six months

or 182 days, whichever is longer, from the date of occurrence. A claim seeking damage to

real property must be filed within one year of the occurrence. A claim relating to any cause

of action other than personal injury, wrongful death, property damage and crop damage

must be presented no later than one year after the incident date. (See Government Code

Section 911.2.)

If you decide to file a claim for damages with the City, then please return the original claim

form along with documentation of the amount claimed to City’s office of record – the office

of the City Clerk.

To submit a claim form via US mail please use this address:

City Clerk

City of Santa Barbara

P.O. Box 1990

Santa Barbara, CA 93102-1990

To submit a claim form by personal delivery please use this address:

City Clerk

City of Santa Barbara

735 Anacapa Street

Santa Barbara, CA 93101

The Risk Management staff will investigate and process the claim upon receipt of the

formal documents from the Clerk’s office. Risk Management staff will contact you upon

receipt of the claim and at the conclusion of the investigation. Please direct any questions

about these instructions or an existing claim for damages to the Risk Management Division

at (805) 897-2585.



________________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________________

For Risk Management Use Only:

Received by _____

via

For City Clerk Use Only:

U.S. Mail

Interoffice Mail

Over the Counter

CLAIM FOR DAMAGES AGAINST THE CITY OF SANTA BARBARA

Be sure your claim is against the City of Santa Barbara and not another public entity. Where space is insufficient, please

use additional paper and identify by paragraph number. Completed claims must be mailed or delivered to:

The City Clerk, City of Santa Barbara, City Hall, De La Guerra Plaza/P.O. Box 1990, Santa Barbara, CA 93102.

The undersigned respectfully submits the following claim and information relative to damage to persons and/or property

against the City of Santa Barbara in accordance with the provisions of CA Government Codes Section 910.

1. Name of Claimant: ___________________________________________________________________________

a. Post Office Address of Claimant:______________________________________________________________

b. City: _________________________ State: ____________ Zip: ___________________________________

c. Phone No: (Optional): _____________________________________________________________________

d. E-Mail Address (Optional): __________________________________________________________________

2. Name, telephone number and post office to which claimant desires notices to be sent (if other than above):

3. Occurrence or event from which claim arises:

a. DATE: ___________ b. TIME:______________

c. PLACE (specify or describe to allow investigator to locate; attach diagram, if possible):

d. How and under what circumstances did damage or injury occur? Specify the particular occurrence, event,

act or omission you claim caused the damage or injury:

e. What particular action by the City or its employees caused the alleged damage or injury?

4. Describe property damage, injury or loss, so far as is known at the time of this claim. If none, state “no

injuries” or “no property damage.”

______________________________________________________________________________________

__________________________________________________________________________________

______________________________________________________________________________________

10.

11.

12.

13.

14.

Name(s) of the City employee(s) causing the damage and/or injury:

Name and address of any other person injured:

Name and address of the owner of any damaged property:

a. Amount of damages claimed as of this date: $ ____________________

b. Estimated future damages: $ ____________________

c. Total damages claimed: $ ____________________

d. Attach and describe the basis for calculation of damages claimed, including medical bills, invoices,

estimates, payroll records, photographs, etc.:

e. If total damages exceed $10,000, jurisdiction is in (check one):

Municipal court (claims up to $25,000) [ ] or Superior court (claims over $25,000) [ ]

Names, addresses and phone numbers of all witnesses, hospitals, doctors, etc.:

a. __________________________________________________________________________________

b. __________________________________________________________________________________

c. __________________________________________________________________________________

d. ___________________________________________________________________________________

Any additional information that might be helpful in considering claim (attach any photographs and/or diagrams):

If this is a claim for indemnity, on what date were you served with the underlying lawsuit? ____ /____ /_____

Does your claim include a claim for bodily injury? Check one: Yes No

If you checked yes to Question #12, please provide the following information as required by federal law. Section

111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) requires the reporting of specific

information about Medicare beneficiaries who have other insurance coverage.

a. Date of Birth: _________________

b. Social Security Number: _________________

c. Sex: Male: Female

Date: _____________________ __________________________________________________

Signature of Claimant or Attorney for Claimant or Legal

Guardian or Parent of Minor or Incapacitated Claimant

WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (Penal Code §72)

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