__[Attorney name]__
__[Telephone number]__

Attorney for Claimant, __[name]__

Claim of __[name]__        )   APPLICATION FOR LEAVE TO PRESENT
                                                                          )LATE CLAIM (Govt C 911.4)
against                                     )
__[Name of entity]__       )
_________________________  )

To __[title of governing body]__ of __[name of entity]__:
     1.   Claimant, __[name]__, applies under Government Code
section 911.4 for leave to present the claim that is attached to
and presented with this application.
     2.   On __[date cause of action accrued]__, claimant
acquired a cause of action against __[name of entity]__ for
__[state general nature of cause of action]__. The date, place,
and circumstances giving rise to this cause of action are set
forth in the attached claim.
     3.   Claimant has not presented this claim earlier for the
following reasons: __[State reasons; see 17.23]__.
     4.   All notices and communications concerning this claim
should be sent to __[attorney's name and address]__.
     WHEREFORE, claimant asks that you grant this application,
deem the attached claim to have been presented on your receipt of
this application, and act on the claim as required by Government
Code section 911.6.

Date: _ _ _ _ _ _                                          [Signature]
                                                                                                                                                                                    __[Typed name]__
                                                                                                                                            Attorney for _ _ _ _ _ _ _ _ _


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Legal Forms : Set Two