PLEASE TYPE OR PRINT CLEARLY, ALL OF THE INFORMATION REQUESTED ON THE CLAIM FORM. YOU MUST COMPLETE EACH SECTION OR YOUR CLAIM MAY BE RETURNED TO YOU AS INSUFFICIENT. THE FOLLOWING PROVIDES SPECIFIC INSTRUCTIONS FOR COMPLETING EACH SECTION OF THE CLAIM FORM.
1. NAME AND MAILING ADDRESS OF CLAIMANT - State the full name and mailing address of the person/persons claiming damage or injury.
Please include a daytime and evening telephone number.
2. WHEN DID THE DAMAGE OR INJURY OCCUR? - State the exact month, date, year, and approximate time (if known) of the incident that caused
the alleged damage/injury.
Under State law, claims relating to causes of action for personal injury, wrongful death, property damage, and crop damage must be presented to
the City of Martinez no later than six months after the incident date. Please note that evidence of "presentation" includes a clear postmark date
on an envelope or a certification of personal service, or service by mail.
When filing a claim beyond the six month period, you must explain the reason the claim was not filed within the six month period. This explanation
is called "application for leave to present a late claim." In considering your claim, the City will first decide whether the late claim application
should be granted or denied. (See Government Code Section 911.4 for the legally acceptable reasons a claim may be filed late.) Only if your late
claim application is granted will the City then consider the merits of your claim.
Claims relating to any cause of action other than personal injury, wrongful death, property damage, and crop damage must be presented no later
than one year after the incident. (See Government Code 911.2.)
1. AT WHICH LOCATION DID THE DAMAGE OR INJURY OCCUR? - Please indicate street, address, city, county, intersection, etc. If possible, also
include the Police Report number.
2. WHAT HAPPENED AND WHY IS THE CITY RESPONSIBLE? - Please explain the circumstances that led to the alleged damage or injury. State
all facts that support your claim with the City and why you believe the City is responsible for the alleged damage or injury. If known, identify the
name of the City Department(s) and/or City employee(s) that allegedly caused the damage or injury.
3. WHAT DAMAGE OR INJURY OCCURRED? - Provide in full detail a description of the damage/injury that allegedly resulted from the incident.
(What specific damage or injury do you claim resulted from the alleged actions?)
4. CLAIM AMOUNT - State the specific total dollar amount you are claiming as a result of the alleged damage/injury. If damage/injury is continuing or
is anticipated in the future, indicate with a "+" following the dollar figure if $10,000 or under. If the total dollar amount is unspecified or exceeds
$10,000, designate the appropriate court jurisdiction for the claim.
5. HOW DID YOU ARRIVE AT THE AMOUNT CLAIMED? - Provide a breakdown of how the total amount that you are claiming was computed. You
may declare expenses incurred and/or future, anticipated expenses. If you have supporting documentation (i.e. bills, payment receipts, cost
estimates), please attach copies of them to your claim.
6. SIGNATURE - The claim must be signed by the claimant or by the attorney/representative of the claimant. The City will not accept the claim
without a proper signature. Government Code Section 910.2 provides: "The claim shall be signed by the claimant or by some person on his/her
behalf."
7. OFFICIAL NOTICES AND CORRESPONDENCE - Provide the name and mailing address of the person to whom all the official notices and other correspondences from the City should be sent, only if other than claimant. Please provide telephone numbers for the representative, if applicable.
THANK YOU!
