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2. 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