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MILLCREEK CLAIM FORM IMPORTANT: This information /form is provided as a service by Millcreek and is not legal advice. You are responsible for compliance with the current requirements of the Governmental Immunity Act of Utah. Millcreek makes no warranty or representation that the information requested by this form satisfies the requirement of the Utah Governmental Immunity Act. This information/form is not a waiver of any of the provisions of the Governmental Immunity Act of Utah. In general, to make a claim against Millcreek for personal injury or property damage, you are required to comply with the provision of the Governmental Immunity Act of Utah. For informational purposes the Governmental Immunity Act of Utah is codified at Utah Code Ann. § 63G-7-101 et seq. This Millcreek Claim Form must be signed by the individual making the claim or by his or her legal representative and delivered by hand or mailed. emails and/or facsimiles are NOT acceptable. Included relevant documents that you deem necessary such as police reports, witness statements, photos, and repair estimates. Add additional pages to the Millcreek Claim Form as you deem necessary. Mail or/and deliver the completed Millcreek Claim Form to: City Recorder 1330 E Chambers Avenue Millcreek, UT 84106 ---PAGE BREAK--- MILLCREEK CLAIM FORM Claimant’s Last Name: Claimant’s First Name: Claimant’s Mailing Address: Claimant’s Telephone and E mail: Date of Incident: Time of Incident: Location of Incident: Claimant’s Vehicle Information (if any): Police Case Number (if any): City Employee Involved (if any): Brief Statement of Facts: IMPORTANT: This information /form is provided as a service by Millcreek and is not legal advice. You are responsible for compliance with the current requirements of the Governmental Immunity Act of Utah. Millcreek makes no warranty or representation that the information requested by this form satisfies the requirement of the Governmental Immunity Act of Utah. This information/form is not a waiver of any of the provisions of the Governmental Immunity Act of Utah. ---PAGE BREAK--- MILLCREEK CLAIM FORM Nature of Claim Asserted: Damages /Injuries Incurred to date: Claimant’s Signature Date Signed IMPORTANT: This information /form is provided as a service by Millcreek and is not legal advice. You are responsible for compliance with the current requirements of the Governmental Immunity Act of Utah. Millcreek makes no warranty or representation that the information requested by this form satisfies the requirement of the Governmental Immunity Act of Utah. This information/form is not a waiver of any of the provisions of the Governmental Immunity Act of Utah.