Information And Claim Form (Page 4 of 4) in pdf

Information And Claim Form Page 4

List the name of the State Bar employee(s) against whom the claim is filed, if any:

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:

For claims involving real property, list the location or address of the incident:

Describe the specific damage or injury (You may attach extra pages if necessary):

Explain the circumstances that led to the damage or injury (You may attach extra pages if necessary):

Explain why you believe The State Bar of California is responsible for the damage or injury (You may attach

extra pages if necessary):

Notice and Signature

I declare under penalty of perjury under the laws of the State of California that all the information I have

provided is true and correct to the best of my information and belief. I further understand that if I have

provided information that is false, intentionally incomplete, or misleading I may be charged with a felony

punishable by up to four years in state prison and/or a fine of up to $10,000 (California Penal Code § 72).

Signature of Claimant or Representative

Date

Mail the original and three copies of this form, along with three copies of all supporting documents to:

The State Bar of California

180 Howard Street

San Francisco, CA 94105

Attention: CLAIMS OFFICER/OFFICE OF THE SECRETARY

Forms can also be hand-delivered to: The State Bar of California, 180 Howard Street, San Francisco, CA,

marked “Attention Claims Officer, Office of the Secretary,” during regular business hours (8:45 a.m. to 5:00

p.m.), Monday though Friday.

Electronic versions of this form can be found on the web site of The State Bar of California at:

State Bar Claim Form (last revised November 2005)

Information And Claim Form Page 4