CLAIM AGAINST COUNTY OF PLACER

INSTRUCTIONS FOR FILING

A Claim Against the County of Placer for any sum of money must be filed with the Clerk of the Board of Supervisors. Such claim must be filed within six (6) months from the date of incident you or your personal property have been injured or damaged. If your claim concerns damage to real property (including any buildings) it must be filed within one (1) year from the date the incident caused the damage.

If an additional report or information is being submitted, it must be complete and detailed. Photographs and repair estimates for damaged property may also be included.

If you fail to file the claim within the required time, you may be precluded from receiving payment.

Once your claim has been filed, it will be reviewed by the Board of Supervisors and either paid or rejected. If you desire to consult an attorney regarding this matter, you should do so immediately.

Claimant Name:

Last Name

First Name

MI

Address:

Address

Address line 2

City

State Value is not selected

Zip

IF ADDRESS FOR RECEIVING NOTICES IS DIFFERENT THAN STATED ABOVE, PLEASE INDICATE HERE:

Business Telephone

Home Telephone

Email Address

Date of Birth

Driver's License #:

Date of Incident

Time of Incident (AM / PM)

Place of Incident

Name of County employees involved (or mark "unknown")

DESCRIPTION OF HOW THE INCIDENT OCCURRED AND WHY PLACER COUNTY IS AT FAULT:

DESCRIBE DAMAGES, INJURIES, AND AMOUNT OF MONEY YOU ARE CLAIMING: (if claim involves an automobile, provide make, model, year, and registered owner information)

Supporting Documentation

Upload supporting documentation

WARNING: IT MAY BE A CRIMINAL OFFENSE TO PRESENT A FALSE/FRAUDULENT CLAIM.

I HAVE READ THE ABOVE CLAIM AND CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Signed this day of:

At (Location in California)

Claimant's Signature

Prove you are human

Submit Date Time DT

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