HomeMy WebLinkAbout2022 Claim Against the CityFillableCLAIM AGAINST THE CITY OF PALM DESERT
For Damage(s) to Person(s) or Personal Property
ASSIGNED CLAIM NO. ______________
Received by: ______________ Via: U.S. MAIL______ Interoffice Mail ______ Over-the-Counter______
TO THE HONORABLE MAYOR AND CITY COUNCIL, CITY OF PALM DESERT, CALIFORNIA:
The undersigned respectfully submit(s) the following claim and information relative to damage(s) to
person(s) and/or personal property:
1.CLAIMANT INFORMATION
NAME _________________________________________________________________________
ADDRESS ______________________________________________________________________
PHONE NO. (_____) ___________________ DATE OF BIRTH: ___________________________
DRIVER’S LICENSE NO.__________________
2.Name, telephone number and post office address to which claimant desires notices to be sent, if
different than above:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3.Occurrence or event from which the claim arises:
a.DATE:________________ b. TIME: ____________ c. PLACE (Exact and specific location)
__________________________________________________________________________
__________________________________________________________________________
d.How and under what circumstances did damage or injury occur? Specify the particular
occurrence, event, act or omission you claim caused the injury or damage. (Use additional
paper if necessary.)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
e.What particular action by the City, or its employees, caused the alleged damage or injury?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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A claim must be filed with the City Clerk of the City of Palm Desert within six (6) months
after which the incident or event occurred. Be sure your claim is against the City of Palm
Desert, not another public entity. Where space is insufficient, please use additional paper
and identify information by paragraph number. Completed claims must be mailed
or delivered to the City Clerk, City of Palm Desert, 73-510 Fred Waring Drive,
Palm Desert, CA 92260
4.Give a general description of the indebtedness, obligation, injury, damage, or loss incurred so far as
it may be known at the time of presentation of the claim. If there were no injuries, state “no injuries”:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
5.Give the name(s) of the City employee(s) causing the damage or injury:______________________
________________________________________________________________________________
6.Name and address of any other person(s) injured:________________________________________
________________________________________________________________________________
________________________________________________________________________________
7.Name and address of the owner of any damaged property:_________________________________
________________________________________________________________________________
________________________________________________________________________________
8.Damages Claimed:
a. Amount claimed as of this date:$ _______________________
b. Estimated amount of future costs:$________________________
c. Total amount claimed:$________________________
d. Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc.):
_____________________________________________________________________________
_____________________________________________________________________________
9.Names and address of all witnesses, hospitals, doctors, etc.:________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
10. Any additional information, including police reports, which might be helpful in considering this claim:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (CALIFORNIA PENAL
CODE 72 AND CALIFORNIA INSURANCE CODE)
I have read the matters and statements made in the above claim, and I know the same to be true of my
own knowledge, except as to those matters stated upon information or belief as to such matters, I believe the
same to be true. I certify under penalty of perjury that the foregoing is TRUE AND CORRECT.
Signed this __________ day of __________________, 20_____, at ______________________________.
_______________________________________ ______________________________________
SIGNATURE OF CLAIMANT SIGNATURE OF CLAIMANT
Office of the City Clerk, Palm Desert, California DOC. NO._______________DATE FILED___________
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