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Claims Against Saratoga

2. Claims must be filed according to Government Code Section 900 et.seq.

   Claims must be filed according to Government Code Section 900 et.seq.

4. First Name*

5. Last Name

7. Address

9. City

10. State

11. Zip Code

13. Cell Phone Number*

14. Home Phone Number

16. Email Address

17. Driver's License Number

19. Amount of Claim

    (Attach copies of bills/estimates)

21. If amount is more than $10,000, indicate where jurisdiction rests:

    1. Superior Court - Limited Jurisdiction

    1. Superior Court - Unlimited Jurisdiction

23. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident

24. Location of Incident

26. Describe the incident, including your reason for believing that the City is liable for your damages:

28. Describe all damages which you believe you have incurred as a result of the incident:

30. Names of Witnesses

31. Upload Additional Sheets as Necessary

33. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
35. Electronic Signature of Claimant

36. Date
    Date

38. Address to which notices are to be sent (if different from above):

40. First Name

41. Last Name

43. Address

45. City

46. State

47. Zip Code

Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit Submit and Print

* indicates a required field