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06/20 CLAIM FOR MONEY OR DAMAGES Please send to: CITY CLERK, CITY OF MODESTO, P.O. Box 642, Modesto, CA, 95353 [PHONE REDACTED] Acknowledgement Name of Address (State):____ (Zip Claimant’s Telephone Notices to be sent to: (if other than to above address) a. Relation to b. Address c. Telephone Provide information in detail regarding the claim: a. What damages and/or injury did you suffer – describe in detail: b. c. How did damage and/or injury d. State why you believe city is responsible or e. Identify city employee(s) causing damage or f. Amounts claimed (personal injury): (property damage) (Attach supporting medical bills, invoices, repair estimates, etc.) 1. If your claim does not exceed $10,000 indicate whether your claim would be a limited civil case (if the amount claimed does not exceed $25,0000 it is treated as a limited civil case): The total claim does not exceed $25,000 The total claim exceeds $25,000 List names, addresses, phone numbers of any List names, addresses, phone numbers of hospital, clinics, List your insurance company, name, address and payments made if In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at NOTE: Presentation of a false claim is unlawful (Cal Penal Code Sec 72) Signature I understand that the claim must be filed with the City Clerk no later than Six mohths after date of incident (see Government Code Section 910 et seq) SIGN