Government Claims Program Information And Claim Form Page 3
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4State of California
Government Claims Form
California Victim Compensation and Government Claims Board
P.O. Box 3035
Sacramento, CA 95812-3035
For Office Use Only
1-800-955-0045 ▪
Claim No.:
Is your claim complete?
New! Include a check or money order for $25 payable to the State of California.
Complete all sections relating to this claim and sign the form. Please print or type all information.
Attach receipts, bills, estimates or other documents that back up your claim.
Include two copies of this form and all the attached documents with the original.
Claimant Information
Tel:
Last name
First Name
MI
Email:
Mailing Address
City
State
Zip
Best time and way to reach you:
Is the claimant under 18?
Yes
No
If YES, give date of birth:
MM
DD
YYYY
Attorney or Representative Information
Tel:
Last name
First Name
MI
Email:
Mailing Address
City
State
Zip
Relationship to claimant:
Claim Information
Is your claim for a stale-dated warrant (uncashed check) or unredeemed bond?
Yes
No
State agency that issued the warrant:
If NO, continue to Step
.
Dollar amount of warrant:
Date of issue:
MM
DD
YYYY
Proceed to Step
.
Date of Incident:
Was the incident more than six months ago?
Yes
No
If YES, did you attach a separate sheet with an explanation for the late filing?
Yes
No
State agencies or employees against whom this claim is filed:
Dollar amount of claim:
Limited civil case ($25,000 or less)
If the amount is more than $10,000, indicate the type
of civil case:
Non-limited civil case (over $25,000)
Explain how you calculated the amount:
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