CLAIM AGAINST THE CITY OF PALO ALTO

Please Submit form to the City Clerk’s Office.

(Attach additional Pages as Necessary)



1. Claimant’s Name

2. Send Official Notices and Correspondence to:

Home Address

Address

City

State

Zip

City

State

Zip

Phone number (Daytime)

Phone number (Evening)

Phone number (Daytime)

(Evening)

3. Date of Birth (optional)

4. Date of Incident

5. Time of Incident (AM or PM)

6. Location of Incident or Accident

7. Claimant Vehicle License Plate #

Vehicle Type

Vehicle Year

8. Basis of Claim. State in detail all facts and circumstances of the incident. Identify all persons, entities, property and City departments involved. State why you believe the City is responsible for the alleged injury, property damage or loss.

Name and Department of city employee who allegedly caused injury or loss

Type of City Vehicle

Vehicle License Number

9. Description of Claimant’s injury, property damage or loss



10. Amount of Claimant’s property damage or loss and method of computation. Attach supporting documentation.

ITEMS


$

$

$

$

TOTAL AMOUNT

$

Court Jurisdiction: (Check one)

Limited Civil: Unlimited Civil:

11. Witnesses Name(if any)

1.

Address

Telephone

2

12.

____________________________

Signature of Claimant or Representative



______________

Date

Do Not Write In This Space (Clerk Stamp)



_______________________________

Print Name



______________

Relationship to Claimant


Choose a file to upload:


CRIMINAL PENALTY FOR PRESENTING A FALSE OR FRADULENT CLAIM IS IMPRISONMENT OR FINE OR BOTH. (PENAL CODE §72)


061220 jp 710022

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