Claim of _____[name]______  ) APPLICATION FOR LEAVE
                            ) TO PRESENT LATE CLAIM
against                     ) Govt C ( §911.4)
                            )
___[name of entity]_________)
____________________________)

To the Board of Supervisors (or other governing body) of ____[name of entity]________:

1. [Your name] hereby applies to the County of _______ for leave to present a claim against the County of ___________, pursuant to Section 911.4 of the California Government Code.
2. The cause of action of [your name] as set forth in his/her proposed claim attached to this application, accrued on _________, 20__, a period within one year from the filing of this application.
3. [Your name]’s reason for the delay in presenting his/her claim against the County of ____________ is as follows: [specify facts justifying delay in filing the claim].
4. All notices and communications concerning this claim should be sent to ____[your name & address]_____________________.

WHEREFORE, claimant asks that you grant this application, deem the attached claim to have been presented on your receipt of this application, and act on the claim as required by Government Code section 911.6

Dated:___________________

_________________________________
Signature