San Manuel Tribal Court
San Manuel Indian Reservation
3214 Victoria Avenue
Highland, CA 92346
Phone: (909) 907-6920
PETITION FOR REVIEW
Petitioner Request for Review of a Decision of the
San Manuel Band of Mission Indians Claims Administrator
Form approved by Judiciary Committee
NOA-RR-001 • 12/20
*If you need more space, please check this box to indicate
an additional document is attached.
Page 1 of 2
1. Petitioner Name and Title/Petitioner Attorney Name and Title:
2. Petitioner Address:
3. Petitioner Telephone Number: Petitioner Email Address:
4. Agency Name:
San Manuel Band of Mission Indians Claims Administrator
5. Date of Claims Administrator's Decision or Deemed
Denial:
6. Statement of Trial Court’s Jurisdiction:
This Request for Review is being led pursuant to the jurisdiction of the San Manuel Tribal Court to resolve disputes
regarding decisions of the San Manuel Claims Administrator as set forth in 1) Section 12.5(b) of the Tribal-State Gaming
Compact between the State of California and the San Manuel Band of Mission Indians, effective April 10, 2017, as
amended; and 2) the San Manuel Gaming Facility Tort Liability Act, San Manuel Tribal Code Chapter 15.
7. Describe the Claims Administrator's Decision (or attach a printed copy to this form)
Please include a concise statement of the Claims Administrator's decision; include copy of letter from the Claims Administrator, if available:
8. Describe the Relief You are Seeking from the Tribal Court
Please include the nature of the relief being sought:
9. Describe the Reasons You are Requesting Review of the Claims Adminstrator's Decision:
