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Claim Against County of Nevada

  1. Return Signed Claim Form to:

    Clerk of the Board of Supervisors
    County of Nevada
    Eric Rood
    Administrative Center
    950 Maidu Avenue
    Nevada City, CA 95959-8617

  2. Type of Claim

  3. For each claimant, please provide the following:

  4. 1. Name of Claimant:

  5. Day

  6. Evening

  7. 2. Name, telephone number, and mailing address to which claimant desires notices to be mailed (if different from item 1):

  8. Day

  9. Evening

  10. 3. If claim involves a vehicle, include:

  11. Police report taken?

  12. 6. Location where loss occurred. (If loss is the result of a vehicle accident: provide city, street , cross street)

  13. 9. Name and address of any other person(s) injured.

  14. 10. Name and address of the owner(s) of any damaged property.

  15. 11. Names and addresses of all witnesses, hospitals, doctors, etc.

  16. 14. If total damages are less than $10,000:

  17. 15. If damages are equal to or greater than $10,000, check appropriate box:

  18. In presenting any claim not founded upon contract, full details as to the nature of the claim, when and where it arose, the public property and officers or employees alleged to be at fault, the nature, extent and amount of the injury or damage claimed, and all other details necessary to a full consideration of the merit and legality of such claim shall be stated in writing, signed by the claimant or someone authorized by claimant. (For further particulars regarding filing of the Claim, see Section 900. et seq. of the California Government Code.)

    Warning: It is a criminal offense to file a false claim. (Penal Code Section 72; Insurance Code Section 556.1)

    I have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters stated upon information or belief, and as to such matters I believe the same to be true. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

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