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Liability Claim Form

(Cal. Gov’t Code §§ 900 et seq.)

Please upload additional pages as necessary to describe the claim and include copies of supporting documentation for the amount(s) claimed. Please fill out claim form completely. Missing information may result in a denial or a delay in the processing of your claim. Claims are a public record.

CLAIMANT(s) OR REPRESENTATIVE OF CLAIMANT(s) HEREBY PRESENT(s) THIS CLAIM
FOR MONEY OR DAMAGES TO THE CITY OF LINCOLN

Type of Loss
 


When did injury / damage occur?

Day of Week
 
Any witnesses?
 
Any City Employee(s) Involved?
 
Total Amount of Claim
 
Does this claim relate to an automobile accident?
 
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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM (Penal Code section 72; Insurance Code section 556.1)


I have read the matters and statements made in this claim and I know the same to be true 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 to the best of my knowledge the foregoing is true and correct.

Are you the claimant or representative?
 
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