Government Claims Program Information And Claim Form Page 2
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4Provide a daytime telephone number, including area code, for the attorney or representative.
Provide an email address for the attorney or representative. (Optional)
Provide a complete mailing address for the attorney or representative.
Describe the relationship of the attorney or representative to the claimant.
If this claim is regarding a stale-dated warrant (an uncashed check) more than three years old, or for an
unredeemed bond, provide the date of issue, amount, and the name of the agency that issued it. Attach a
copy of the front and back of the warrant or bond. For warrants that are less than three years old,
contact the agency that issued the warrant directly to obtain payment.
State the exact date of the incident that you believe caused the damage or injury. If the incident took place
over more than one date, provide both the beginning and ending dates. If the incident is ongoing, please
provide the beginning date and the most recent date it occurred.
Late Claims: The Board must receive claims relating to the death or injury of a person, or damage to
personal property or growing crops, no later than six months after the date of the incident. If such a claim is
filed more than six months from the date of the incident, attach a written explanation for late filing to the
claim on a separate sheet. Other claims that have deadlines must be received no later than one year after
the incident date. Other claims have no filing deadline. Claimants may wish to consult with an attorney to
determine which filing deadline applies.
Provide the name of the state agency that you believe caused the damage or injury. “State of California”
alone is not sufficient. Please spell out the name of the agency and include the names of any state
employees that were involved.
Enter the total dollar amount being claimed. If you believe the damages are continuing, or anticipated in the
future, show a “+” after the dollar amount. If the total dollar amount exceeds $10,000, note whether the claim
is a limited civil case or a non-limited civil case. Provide an explanation of how you computed the total
amount. You may declare expenses incurred as well as expenses you expect to have in the future. Attach
copies of all bills, payment receipts, and cost estimates.
For all claims involving real property, state-owned buildings or parking lots, and roadway- or vehicle-related
claims, provide the street address, city, county, state highway number, road numbers, and/or post mile
markers where you believe the damage or injury occurred. Real property includes land, buildings and other
fixed structures. Roadway- or vehicle-related claims occurred on a state road or involved a state vehicle.
Describe the specific damage or injury that you believe resulted from the incident. Feel free to attach
additional information to explain
through
.
Describe in full detail the circumstances that led up to the damage or injury. State all the facts that support
your claim. If it applies, describe the dangerous condition of the public property. If a law enforcement or
insurance Collision/Incident Report is submitted with the claim, this section must still be completed in your
own words.
Explain why you believe the state agency is responsible for the damage or injury.
Provide the vehicle license number and any other identifying information if the claim involves a state vehicle.
This section must be completed if the claim involves a motor vehicle. Indicate whether a claim has been filed
with your insurance carrier. If a claim has been filed with your insurance carrier, provide the name,
telephone number, and mailing address of the insurance carrier. Also include your policy number and the
amount of the deductible. If you have received payment, please indicate when and the dollar amount.
The claimant or the claimant’s attorney or representative must sign this form. The Board will not accept the
claim without an original signature.
Be sure to attach the $25 filing fee. Please make your check or money order payable to the State of
California. If you cannot afford the filing fee, you can fill out a “Filing Fee Waiver Request”, and attach it to
this form. You obtain the filing fee waiver request form at or by calling 1-800-
955-0045.
State agencies must submit the agency name, contact information for the agency budget officer, and the
name of the fund or budget act appropriation item number. Submit the appropriate schedule if applicable
(Example: 0000-000-0000, Budget Act 2004).
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