Marysville School District Standard Tort Claim Form Packet (Page 5 of 5) in pdf

Marysville School District Standard Tort Claim Form Packet Page 5

17. Names, addresses and telephone numbers of treating medical providers. Attach copies of all

medical reports and billings.

Please attach documents which support the claim’s allegations.

I claim damages from Marysville School District No. 25 in the sum of $

This claim form must be signed either by the Claimant or a person holding a written power of attorney from the

Claimant, by the attorney-in-fact for the Claimant, by an attorney admitted to practice in Washington State on

the Claimant’s behalf, or by a court-approved guardian or guardian ad litem on behalf of the Claimant.

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and

correct.

Signature of Claimant

Date and Place (residential address, city and county)

Rev 8/21/15

Marysville School District Standard Tort Claim Form Packet Page 5