Claim Against The City And County Of San Francisco
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1
2CLAIM AGAINST THE CITY AND COUNTY OF SAN FRANCISCO
Before completing this form please read the instructions on the back. Untimely claims will be returned. Please submit
th
this form and supporting documentation to the Controller’s Office, Claims Division, 1390 Market Street, 7
Floor,
San Francisco, CA 94102 in person or by mail.
**
**
= REQUIRED
= REQUIRED IF KNOWN
1. Claimant’s Name and Home Address (Please Print Clearly)
2. Send Official Notices and Correspondence to:
*
*
City
State
Zip
City
State
Zip
Daytime
Evening
Cellular
Daytime
Evening
Cellular
Telephone
Telephone
3. Date of Birth
4. Social Security Number
5. Date of Incident
6. Time of Incident
(AM or PM)
*
**
7. Location of Incident or Accident
8. Claimant Vehicle License Plate #, Type, Mileage, and Year
**
**
9. Basis of Claim. State in detail all facts and circumstances of the incident. Identify all persons, entities, property and City
departments involved. State why you believe the City is responsible for the alleged injury, property damage or loss.
*
Name, I.D. Number and City Department
Type of City Vehicle
Vehicle License Number and Bus or Train Number
of City Employee who allegedly caused injury or loss
**
**
**
11. Amount of Claimant’s property damage or loss and
10. Description of Claimant’s injury, property damage or loss
method of computation. Attach supporting
*
documentation. (See Instructions)
ITEMS
*
$
$
$
$
$
TOTAL AMOUNT
Court Jurisdiction:
Limited (up to $25,000)
Unlimited (over $25,000)
12. Witnesses (if any) Name
Address
Telephone
1.
2.
13.
Do Not Write In This Space
*
Signature of Claimant or Representative
Date
Print Name
Relationship to
Claimant
CRIMINAL PENALTY FOR PRESENTING A FALSE OR
FRAUDULENT CLAIM IS IMPRISONMENT OR FINE OR BOTH.
(PENAL CODE §72)
CA/FORM 02/14
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