Claim Form

(A claim shall be presented by the claimant or by a person acting on his behalf.)
NAME OF DISTRICT:   Bolinas Community Public Utility District
1. Claimant name, address, (mailing address if different) and phone number.
Name:

Address(es):

Phone Number: (          )

2. List name, address and phone number of any witnesses.
Name:

Address:

Phone Number: (           )

3. List the date, time place and other circumstances of the occurrence or transaction which gave rise to the claim asserted.
Date:                   Time:                        Place:

Tell What Happened (give complete information):

NOTE: Attach any photographs you may have regarding this claim.
4. Give a general description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of presentation of the claim.

5. Give the name or names of the public employee(s) causing the injury, damage or loss, if known.

6. If the actual amount of your claim is less than $10,000 indicate the exact amount of your claim, and if possible show specific itemization and/or include copies of any documents in support thereof. If the amount of the claim exceeds $10,000, no dollar amount should be included in this claim form. However, it is necessary to indicate whether jurisdiction will rest in Municipal or Superior Court. (Jurisdiction for any claim under $25,000 would rest in Municipal Court, and any claim over $25,000 would rest in Superior Court.)

Date:                                                   Time:                                                            Signature:
ANSWER ALL QUESTIONS. OMITTING INFORMATION COULD MAKE YOUR CLAIM LEGALLY INSUFFICIENT!