Professional Documents
Culture Documents
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I~~Time of Incident
(AM or PM)
Date of Incident
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9. Basis of Claim. State in detail all facts and circumstances of the incident. Identify all persons, entities, property and City
departments invol.,ed. State why you believe the City is responsible for the alleged injury, property damage or loss.
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TOTAL AMOUNT
Court Jurisdiction:
12. Witnesses (if any) Name
1.
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2.
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Address
Telephone
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Do Not Write In This Space
Date
Print Name
Relationship to
Claimant
CRIMINAL PENALTY FOR PRESENTING A FALSE OR
FRAUDULENT CLAIM IS IMPRISONMENT OR FINE OR BOTH.
(PENAL CODE 72)
CAIFORM 02/14
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