Government Claim (Judicial Branch)

FOR COURT OR OFFICIAL USE ONLY: GOVERNMENT CLAIM (JUDICIAL BRANCH) (GOVERNMENT CODE SECTION 910.4) DATE STAMP Postmark date if received by mail: ___________ CLAIMANT INFORMATION Name of Claimant Mailing Address City Home Telephone State Work Telephone Zip Code Send notices regarding this claim to (if different from above): Name: Mailing Address City State Zip Code CLAIM INFORMATION Date of Incident (Month/Day/Year) Location of Incident Describe the indebtedness, obligation, injury, damage, or loss incurred as a result of the incident. Time of Incident State the circumstances that gave rise to this claim. (State the facts that support your claim and why you believe the court or other judicial branch entity is responsible for the alleged damage or injury.) If known, provide the name(s) of the official(s) or employee(s) who allegedly caused the injury, damage, or loss. If more space is needed, please attach additional sheets. American LegalNet, Inc. www.FormsWorkFlow.com If the total amount of your claim is up to $10,000: Amount of damages as of this date: Estimated amount of future damages: Total amount claimed: _____ _____ _____ If the amount of your claim is more than $10,000, indicate whether your claim would be a limited civil case or unlimited civil case (check one): Limited Civil (amount is $25,000 or less) Unlimited Civil (amount is more than $25,000) State how the amount of your claim was computed (include copies of supporting documentation such as billing statements, invoices, receipts, estimates, etc.). Names, addresses, and telephone numbers of all witnesses to the incident: Any additional information that might be helpful in considering this claim: REPRESENTATIVE INFORMATION (Complete if claim is presented by a person acting on claimant's behalf.) Name of Authorized Representative Mailing Address City Telephone State Zip Code PLEASE NOTE: Presentation of a false claim, with intent to defraud, is a criminal offense. (Penal Code section 72.) Signature of Claimant or Authorized Representative (check one) Date Deliver or mail this claim form to: Attention: Court Executive Officer (Claims) Superior Court of California, County of Fresno 1100 Van Ness Avenue Fresno, CA 93724-0002 American LegalNet, Inc. www.FormsWorkFlow.com