Fillable Form Tc-1 - Claim Against The State Of Nevada (2015) (Page 2 of 2) in pdf

State the full names, addresses and phone numbers of all witnesses:

____________________________________________________________________________________________________

A CLAIM FOR $____________________________ is hereby made against the STATE OF NEVADA, based upon the

following facts:

10.

Describe how damage or injury occurred and what the STATE OF NEVADA or its employees did to cause your damage

or injury. Give full details:

____________________________________________________________________________________________________

A) State of NV Employee’s Name __________________________ B) State of NV Agency __________________________

11.

Explain and support the amount of damages you have claimed by listing each item of damages.

Please provide a MINIMUM OF 2 REPAIR ESTIMATES for property damage. Also include any rental bills, receipts, medical

reports, itemized statements, etc.

____________________________________________________________________________________________________

12.

If this claim is for personal injury and/or payment of medical expenses you must answer this question: Are you covered

under any type of Medicare Program. NO ____

YES ____ if yes: Pursuant to Federal Medicare rules, if liability is

accepted by the State of NV, you will be required, at a later date, to provide your Medicare Health Insurance Claim Number

(HICN).

I, ________________________________, do hereby attest under penalty of perjury that I am the claimant named above, that I

have read the foregoing claim and know the contents thereof, that the same is true of my own knowledge, except those

matters stated upon information and belief, and as to those matters, I believe them to be true, and that THIS IS MY ENTIRE

CLAIM AGAINST THE STATE OF NEVADA.

IF MY CLAIM IS PAID, I FULLY UNDERSTAND THAT I WILL HAVE TO SIGN A GENERAL RELEASE OF ALL CLAIMS IN THE

PRESENCE OF A NOTARY PUBLIC FOR THE EXACT AMOUNT I AM CLAIMING BEFORE ANY PAYMENT WILL BE OFFERED

TO ME. THIS RELEASE WILL BECOME EFFECTIVE ONLY UPON ACTUAL PAYMENT OF THE CLAIM BY THE STATE OF

NEVADA.

______________________________________________

____________________________

Signature of Claimant (or Company Representative)

Date

NOTICE: 197.160 of Nevada Revised Statutes provides that every person who knowingly presents a false claim is guilty of a gross

misdemeanor, and is subject to criminal penalties of imprisonment of up to one year, and a fine of up to $2,000.

Incomplete or unsigned claim forms will not be accepted and will be returned.

Claims may be submitted as follows:

Fax: 775-684-4601 or

Mail:

Claims Manager

DMV Legal/Tort Claims

555 Wright Way

Carson City, NV 89711

Page 2 of 2

TC-1 (revised 11/15)

Form Tc-1 - Claim Against The State Of Nevada (2015) Page 2