COUNTY OF TRINITY

CLAIM FOR DAMAGES

This claim must be filed with the Board of Supervisors within six (6) months after the

accident or event. Where space is insufficient, please use additional paper and identify

information by paragraph number. Please include photographs if applicable.

When claim is complete, mail to:

TRINITY COUNTY BOARD OF SUPERVISORS OFFICE ATTN: CLERK OF THE BOARD

Courthouse

P.O. Box 1613

Weaverville, CA 96093

CLAIMANT:

NAME:___

ADDRESS:

TELEPHONED )_
DATE OF BIRTH____

DRIVER'S LICENSE #

The undersigned respectfully submits the following claim and information:

1. Address to which claimant desires notice(s) to be sent if other than above:

Date, place, and time of occurrence or transaction which gives rise to this

claim:

DATE: TIME:

PLACE:

Specify the particular act or omission and circumstance you believe caused injury and / or damage:

4. Name or names of any employee of the County you believe caused the injury, damage, or loss: