Standard Tort Claim Form (Page 2 of 2) in pdf

11. State the school, department, or person alleged responsible for damage/injury:

_____________________________________________________________________________________________

12. Names, addresses, and telephone numbers of all persons involved in or witness to the incident:

_____________________________________________________________________________________________

13. Names, addresses, and telephone numbers of all employees having knowledge about this incident:

_____________________________________________________________________________________________

14.

Names, addresses, and telephone numbers of all individuals not already identified in #12 and #13 above

that have knowledge regarding the liability issues involved in this incident, or knowledge of the Claimant’s resulting

damages. Please include a brief description as to the nature and extent of each person’s knowledge. Attach

additional sheets if necessary:

_____________________________________________________________________________________________

15.

Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical, or

mental injuries. Attach additional sheets if necessary:

_____________________________________________________________________________________________

16. Has the incident been reported to law enforcement, safety or security personnel? If so, when and to whom?

_____________________________________________________________________________________________

17. Please attach documents which support the claim’s allegations.

18. I claim damages from the Lake Washington School District No. 414 in the sum of $_____________________.

This claim form must be signed by the Claimant, 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 ad litem on behalf of the Claimant.

I declare under penalty of jury 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)

Standard Tort Claim Form Page 2