__[Attorney name]__
__[Address]__
__[Telephone number]__
Attorney for Claimant, __[name]__
Claim of __[name]__ ) CLAIM FOR __[E.G., INJURY
)TO PROPERTY]__
against )
)
__[Name of entity]__ )
_________________________ )
To __[title of governing body]__ of __[name of entity]__:
1. Claimant, __[name]__, whose address is __[specify]__,
claims damages from __[name of entity]__ in __[the amount of $_ _
_ _ _ _/an amount that exceeds $10,000]__ for __[e.g., injury to
claimant's personal property, namely __[describe]__]__.
2. Jurisdiction over this claim would rest in
__[superior/municipal]__ court.
3. This claim is based on __[state nature, date, and place
of occurrence or transaction]__ under the following
circumstances:
[Briefly describe in series of short paragraphs
circumstances entitling claimant to recover from entity]
4. __[Claimant does not know the names of the public
employees who caused claimant's __[injury/damage/loss]__/The
public employees who caused claimant's __[injury/damage/loss]__
are: __[List names]__]__.
5. The __[injury/damage/loss]__ sustained by claimant
consists of __[specify]__.
6. The __[injury/damage/loss]__ expected to be incurred in
the future includes __[specify]__.
7. All notices and communications concerning this claim
should be sent to __[attorney's name and address]__.
Date: _ _ _ _ _ _ [Signature]
_________________________
__[Typed name]__
Return to Table of Contents for
Legal Forms : Set Two