Sample California Notice of Tort Claim:


Note: This form is not offered as qualified legal advice. Consult an attorney immediately.

CLERK

CITY OF [     ]

In the Matter of the Claims of [     ],

for damages   

CLAIM FOR DAMAGES

California Government Code
Section 910 et seq.

[     ], presents her claims, and the claims of all persons whose interests she represents, for damages pursuant to Government Code §910 et seq., and in support thereof shows as follows:

1.    NAME OF CLAIMANT:

[     ]. 
   

2.    ADDRESS OF CLAIMANT:

[     ]

3.    ADDRESS TO WHICH COMMUNICATIONS RE THESE CLAIMS TO BE SENT:
   
[     ]


4.    DATE/DESCRIPTION OF INCIDENT GIVING RISE TO CLAIM:

[     ] 

5.    NAME OF EMPLOYEE RESPONSIBLE FOR INJURIES CLAIMED:

[     ]

6.    INJURIES AND DAMAGES:

[     ]

7.    Wherefore, claimant requests damages as described herein.


DATED:    [     ]       
   

By____________________________
Claimant



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