NOTICE OF CLAIM
Name of Claimant: ________________________________________________________________________________
(Please Print)
Permanent Residence
Address: _______________________________________________________________________________________
(Street/PO Box) (City) (State) (Zip)
Campus/Business Telephone: ________________ Permanent Residence Telephone: ___________________
(Include area code)
Residence Address at Time of Injury (if different from above)
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Property Damage: $_______________ Personal Injury: $_______________ TOTAL $_________________(US dollars)
CLAIMANT MUST provide a short and plain statement of the facts upon which this claim is based (give dates and specific
locations, the time of day the incident occurred; the circumstances which brought about any injury or property damage; and,
a description of and extent of such injury or damage; and, the identity of the property owner). Failure to provide sufficient
information will result in denial of the claim.
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(Use reverse side, if necessary, to continue)
CLAIMANT MUST on the reverse side of this form, list the names (and, if known, the addresses and telephone numbers) of
all persons involved in the incident and/or who witnessed the incident.
As the Claimant, I acknowledge that I must present this claim in person or through registered or certified U. S. Mail to the
Office of General Counsel, 3150 YMCA BLDG, 195 Lee Blvd, P. O. Box 6171, Mississippi State, MS 39762-6171 within
one year of the date of the incident or my claim will be forever barred by law. Further, I acknowledge that the date this claim
is received by the designated official at Mississippi State University is the date that will be considered to be the earliest date
of the claim. In addition, I acknowledge I am required to provide further information if so requested by Mississippi State
University or any other official handling or processing this claim.
As the Claimant, I further state and certify that all of the information provided on this claims form by me is true and accurate
to the best of my knowledge and belief. I understand that if I have supplied, or in the future do supply, information which is
false, misleading, or untrue regarding this claim, I can be prosecuted, fined and/or imprisoned, under the laws of the State of
Mississippi.
________________________________/___________ ________________________________/___________
Signature of Claimant Date Signed Signature of Witness Date Signed
Revised 9/20/18
FOR OFFICE USE ONLY
CLAIM NO. _________
