Claim of [name]         ) CLAIM FOR PERSONAL INJURIES
                        )
                        ) (GOVERNMENT CODE § 910)
against                 )
                        )
                        )
[name of entity ]       )
________________________)

TO THE BOARD OF SUPERVISORS OF ________________ COUNTY:

You are hereby notified that [name of claimant], whose address is ___________________________, claims damages from the County of __________ in the amount computed as of the date of presentation of this claim of $_______________.

This claim is based on personal injuries sustained by claimant on or about _________________, 20____, in the vicinity of [place where injuries were sustained], under the following circumstances:

[Describe generally the facts and circumstances of how you were injured.]

The injuries sustained by the claimant, as far as known, as of the date of the presentation of this claim consist of:

[Describe what injuries you suffered.]

The name(s) of the public employee(s) causing claimant’s injuries under the described circumstances (is) (are)

_____________________________________________.

The employee(s) are employed in the following named County department(s) _____________________________________________.

[If the total amount of the claim is less than $10,000]:

The amount claimed, as of the date of presentation of this claim, is computed as follows:

Damages incurred to date:

Expenses for medical and hospital care                           $__________
Loss of earnings                                                 $__________
Special damages for __[itemize]___                               $__________
                                                                 $__________
General damages                                                  $__________

TOTAL DAMAGES INCURRED TO DATE:                                  $__________

Estimated prospective damages as far as known:

Future expenses for medical and hospital care                    $__________
Future loss of earnings                                          $__________
Other prospective special damages                                $__________
                                                                 $__________

TOTAL ESTIMATED PROSPECTIVE DAMAGES:                             $__________

TOTAL AMOUNT CLAIMED AS OF DATE OF PRESENTATION OF THIS CLAIM:   $__________

[If amount of claim exceeds $10,000]:

Jurisdiction over the claim would rest in (municipal/superior) court. This claim (is/is not) a limited civil case. [If amount of claim is under $25,000, it is a limited civil case and jurisdiction resides in municipal court.]

All notices or other communications with regard to this claim should be sent to claimant at [address to which notices are to be sent].

Dated: _________________

____________________________
Signature