INSTRUCTIONS:
• Read claim thoroughly
• Complete one form for each claimant
• Attached additional information or documents if needed

Name of Claimant:

Telephone Number:

Cell Phone:

Mailing Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code:

Date of Incident:

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 Central Fire District of Santa Cruz County 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 to state the circumstances of the claim, please attach additional documents here.

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

List the names, addresses and telephone numbers of all witnesses to the incident.

Provide any additional information that might be helpful in considering this claim.

REPRESENTATIVE (Complete this section only if the claim is presented by someone acting on the claimant's behalf).

Name of Authorized Representative:

Telephone Number:

Mailing Address:

City:

State:

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code: