__[Attorney name]__
__[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
         [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