FOR COURT OR OFFICIAL USE

5e63a2c7cc5c6f4d5f9656205add640576404aa1

California Superior Local Rules

section 910.4) GOVERNMENT CLAIM—JUDICIAL R NCH 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.

FOR COURT OR OFFICIAL USE Name of Claimant: GOVERNMENT CLAIM—JUDICIAL R NCH If the total amount of your claim is up to $10,000: If the amount of your claim is more than $10,000, indicate whether your claim would be a limited civil Amount of damages as of this date: case or an unlimited civil case (check one): Estimated Total amount claimed: Limited civil (amount is $25,000 or less) Unlimited civil (amount is more than $25,000) State how the amount of your claim was computed (include copies of supporting documentation such as billing statements, invoices, receipts, and estimates).

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 only if claim is presented by someone acting on Name of Authorized Representative Telephone Mailing Address City State Zip Code PLEASE NOTE: of a false claim with intent to defraud is a offense (Penal

section 72). Signature of □ Claimant or □ Authorized Representative (check one) Date Deliver or mail this claim form to: ATTN: GENERAL COUNSEL ORANGE COUNTY SUPERIOR COURT CENTRAL JUSTICE CENTER CIVIC CENTER DRIVE WEST P.O. BOX SANTA ANA, CA 92702-1994

Document details

Collection	California Superior Local Rules
Citation	5e63a2c7cc5c6f4d5f9656205add640576404aa1
Type	court_rule
Language	en
Format	pdf
Source	CA_LOCAL
Identifier	5e63a2c7cc5c6f4d5f9656205add640576404aa1

Source file is stored in the law ingest library (pdf).