Claim Against The City

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Please correct the field(s) marked in red below:

Who is Making the Claim

1
What is your name?
 *
2
What is your address?
 *
3
What is your phone number?

Claim Details

4
What happened?
 *
5
Where did it happen?
 *
6
When did it happen? (Time/Date)
 *
7
What are the damages? (Exact dollar amount of claim)
8

Please upload receipts, estimates or other appropriate documents


Reporting, etc.

9
Who do you believe is at fault, and why?
 *
10
Was the incident reported to anyone else? (i.e. Police, Utilities, Public Works, etc.)
11
Is there any other information not included above?
 *

Sign and Date

12

Signature of Claimant

 *
13
Date:
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