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CLAIM FOR MONEY OR DAMAGES TO: CITY CLERK WARNING CITY OF MODESTO Be sure your claim is filed with the PO Box 642 City Clerk no later than 6 months Modesto, CA 95353 after date of the incident. (see Govern- (209) 577-5446 ment Code Section 910 et seq) 1. Name of Claimant: 2. Address: (Street) (City) (State) (Zip Code) 3. Claimant’s Telephone (Home) (Work) (Other) 4. Claimant’s Email 5. Notices to be sent to: (if other than to above address) a. Name: Relation to Claimant: b. Address (Street) (City) (State) (Zip Code) c. Telephone: (Home) (Work) (Other) 6. Provide information in detail regarding the claim: a. What damages and/or injury did you suffer - describe in detail: b. Date Time Location c. How did damage and/or injury occur: d. State why you believe City is responsible or involved: e. Identify City employee(s) causing damage or injury: f. Amounts claimed (personal injury): $ (property damage) $ (Attach supporting medical bills, invoices, repair estimates, etc) 7. a. If your claim does not exceed $12,500 state the total amount claimed: b. If your claim exceeds $12,500 indicate whether your claim would be a limited civil case (if the amount claimed does not exceed $35,000 it is treated as a limited civil case): The total claim does not exceed $35,000 The total claim exceeds $35,000 8. List names, addresses, phone number of any witness: 9. List names, address, hospital, clinics, physicians: 10. List your insurance company, name address and payments made if any: Note: Presentation of a false claim is unlawful (Cal Penal Code Sec 72) 03/05 Signature of Claimant or Representative SIGN