__[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]__
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Legal Forms : Set Two