COUNTY OF LASSEN - CLAIM FOR DAMAGES
This claim must be filed with the Clerk of the Board of Supervisors within six (6) months after
the accident or event.  Where space is insufficient, please use additional paper and identify
information by paragraph number.  When claim is complete, mail to:
Lassen County Clerk of the Board
220 S Lassen St, Ste 5
Susanville, CA 96130
COUNTY BOARD OF SUPERVISORS					CLAIMANT
Courthouse					NAME:
Susanville, California					ADDRESS:
					TELEPHONE:
					DATE OF BIRTH:
					DRIVER'S LICENSE/I.D. #:
SUPERVISORS:
The undersigned respectfully submits the following claim and information:
1.	Post office address to which claimant desires notices to be sent if other than above:
2.	Date, place, and time of occurrence or transaction which gives rise to this claim:
	DATE:				TIME:
	PLACE:
3.	Specify the particular act or omission and circumstances you believe caused injury
	and/or damage:
4.	Name or names of any employee of the County you believe caused the injury,
	damage or loss:
5.	Description of property damaged:
6.	Owner of property damaged:
	Location of property damaged:
7.	Description of personal injury.  If there was no personal injury, state "NONE":
8.	Name of any other person injured:
9.	Name and addresses of witnesses, doctors, hospitals, etc:
		NAME		ADDRESS				TELEPHONE
	(1)
	(2)
	(3)
10.	Amount of reimbursement claimed as damages with computation and supporting bills,
	receipts or estimates of cost (please attach papers to claim):
11.	If your claim involves a motor vehicle, please provide:
	INSURANCE CARRIER			ADDRESS			PHONE NO.		POLICY NO.
	REGISTERED OWNER OF VEHICLE:
12.	Any additional information that might be helpful in considering claim:
	WARNING! IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!
	(Penal Code 72: Insurance Code 556)
	I have read the matters and statements made in the above claim and I know the same to be
	of my own knowledge, except as to those matters stated upon information or belief and as
	to such matters I believe the same to be true.  I certify under penalty of perjury that the
	foregoing is true and correct.
	SIGNED THIS _______ DAY OF ________________, 2_____, AT _________________
	RETURN  CLAIM  TO:						CLAIMANT'S SIGNATURE
	Lassen County Clerk of the Board
	220 S Lassen St, Ste 5
	Susanville, CA 96130								C:\excel\clerk\forms