City of American Canyon : Form

Survey/Form Review

City of American Canyon Liability Claim Form

10. Witness(es) (Including City Employees):

Name:	Address:	Phone #:
Name:	Address:	Phone #:
Name:	Address:	Phone #:

CITY OF AMERICAN CANYON LIABILITY CLAIM FORM

INSTRUCTIONS: Please complete the form below.

Any person who, with the intent to defraud, presents any false or fraudulent claim may be punished by imprisonment or fine or both.

NOTE: You must file a claim in compliance with Government Code Section 911.2

1. CLAIMANT'S NAME:

2. Claimant's Address:

3. Amount of Claim: Invoices and/or estimates are required, so please email copies of your invoices/estimates to:
claims@cityofamericancanyon.org, or, mail to:

City of American Canyon Claims - HR
4361 Broadway St., Suite 201
American Canyon, CA 94503

4. Home Phone:

5. Work Phone

6. Location of Incident:

7. Date/Time of Incident:

8. Describe the incident/accident. Include your reason for believing that the City is liable for your damages.

9. Describe all damages which you believe are a result of the incident/accident:

11. If amount claimed is over $10,000, indicate where jurisdiction rests:

Limited Civil Case

Unlimited Civil Case

12. Address to which notices are sent, if different from above:

Name:

Phone #:

Address:

13. Date:

By clicking this checkbox, I attest that all statements regarding my claim are true.

Click here

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