Government Claim Judicial Branch printable pdf download

Government Claim Judicial Branch

FOR COURT OR OFFICIAL USE ONLY

[DATE STAMP]

_________

Postmark date if received by mail:

GOVERNMENT CLAIM—JUDICIAL BRANCH

Postmark date if received by mail: ___________

(Government Code section 910.4)

CLAIMANT

Name of Claimant

Home Telephone

Work Telephone

Mailing Address

City

State

Zip Code

Send notices regarding this claim to (if different from above):

Name

Mailing Address

City

State

Zip Code

CLAIM INFORMATION

Date of Incident (Month/Day/Year)

Time of Incident

Location of Incident

Describe the indebtedness, obligation, injury, damage, or loss incurred as a result of the incident.

State the circumstances that gave rise to this claim. (State the facts that support your claim and why you

believe the court or another judicial branch entity is responsible for the alleged damage or injury.) If known,

provide the name of the official or employee who allegedly caused the injury, damage, or loss (if there is more

than one official or employee, name each). If you need more space, please attach additional sheets of paper.

GOVERNMENT CLAIM—JUDICIAL BRANCH

PAGE 1 of 2

Government Claim Judicial Branch