[City of Irvine] Claim for Damages 10-04

Print Document

When you click Print below we will prepare a printable document for you. It will automatically download when it's ready.

Did you know?
You can fill in the document online and then click the print icon and all of your information will be populated in the printable document, saving you time later.

Upload Attachment(s)

Please upload the attachments listed below and click Continue to proceed. Please click Skip if no attachments need to be upload.

There is a 250MB limit on each attachment. Upload only one document per attachment; multiple pages within a document are acceptable.

Describe specific nature of damage or injury (Additional Sheets) Click Here to Upload

Specify how the damage or injury occured (Additional Sheets) Click Here to Upload

Specify what particular act/omission on the part of the City Officers or Public Employees do you claim caused the damage/injury (Additional Sheets) Click Here to Upload

Give the amount claimed as of the date of presentation of the claim, including the estimated amount of any damage/injury/loss, insofar as it may be known at the time of presentation of this claim, together with the basis of computation of the amount claimed, with estimates and bills, if appropriate (Additional Sheets) Click Here to Upload

Skip

	Signer Details	Me?
Claimaint or Representative of Claimant
I'm not a signer listed above

City Clerk's Office Legislative Services

Print Document

Create Your Signature

Upload Attachment(s)

Sign Now!

Please provide accurate information below to ensure the delivery of the signed copies of the document.

Listed Signers