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(Revised
5/2019)
WYOMING LOCAL GOVERNMENT - NOTICE OF CLAIM
THIS CLAIM FORM MAY BE RETURNED IF ALL REQUIRED SECTIONS (*) ARE NOT COMPLETED.
The following claim is submitted as an itemized written claim in accordance with the Wyoming Governmental
Claims Act (W.S. 1-39-113). NOTE: This claim form is to be completed by the claimant, signed in the presence of
a notary public, and submitted to the governmental entity that your claim is against.
*GOVERNMENTAL ENTITY NAME that you are filing a claim against; i.e., the city, town, county, special district,
etc. (if known, include the name of the Department and employee involved in incident)
_____________________________________________________________________________
Address:_______________________________________________________________________
*CLAIMANT INFORMATION: (MUST BE OWNER OF DAMAGED PROPERTY) NOTE: If a minor is involved
(under 18), the parent or guardian must complete and sign the claim form and state they are doing so on behalf
of the minor. Please enter business name and address if property of business was damaged:
Full Name:____________________________________________________________________
Mailing Address:________________________________________________________________
City_____________________________________State________________Zip______________
Providing a phone number and email address may expedite your claim.
Cell: Other Daytime Phone:
FAX: Email:
NOTE: GOVERNMENTAL CLAIM FILES ARE CONFIDENTIAL BY STATE STATUTE.
Physica
l Address (if different from mailing address)
___________________________________________________________________________
City________________________________________State______________________Zip___________________
*DATE AND TIME OF LOSS (if unknown, please state date of discovery):
Date:_________________________________________Time _____________AM___PM___(Check one)
(Month, Day, Year) Please note that noon is 12:00 P.M.
*SPECIFIC LOCATION OF LOSS OR INJURY: (Where did the incident occur?):
Address/Street/Hwy___________________________________________________________________
City/Town/Building____________________________________________State____________________
*PLEASE DESCRIBE IN DETAIL THE CIRCUMSTANCES OF THE LOSS AND/OR INJURY
(YOUR ACCOUNT OF WHAT HAPPENED IS VERY IMPORTANT.) Additionally, you may submit photos, statements
from witnesses, estimates for repair, receipts, or any other information that would support your claim.
Please attach additional narrative to this claim form if more space is needed. If there are multiple claimants for one
occurrence, each individual claimant must file a “Notice of Claim” form.
Town of Jackson office use only:
DATE CLAIM WAS RECEIVED:_______________________
