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.