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Gilroy USD |  E  3320  Business and Noninstructional Operations

Claims And Actions Against The District   

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CLAIM FORM AGAINST GILROY UNIFIED SCHOOL DISTRICT

Government Code Sections 910 and 910.2

Name of Claimant: _____________________________ Telephone: ____________________

Address: __________________________________________________________________

City: _______________________________ State: __________________

Address to Be Sent To If Different From Above:

________________________________________________________________________

________________________________________________________________________

When did damage or injury occur?

________________________________________________________________________

Where did damage or injury occur?

________________________________________________________________________

How and under what circumstances did damage or injury occur?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

What particular action by the district or its employees caused the alleged damage or injury?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

What sum do you claim? Include the estimated amount of any prospective loss insofar as it may be known at the time of the presentation of this claim, together with the basis for computation of the amount claimed. (attached estimates or bills, if possible)

_____________________________________________________ $__________

_____________________________________________________ $__________

_____________________________________________________ $__________

Total Amount Claimed $_______________

Names and addresses of witnesses, doctors, and hospitals:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

___________________________________ _______________________________

Signature of Claimant Date

Notice: Section 72 of the California Penal Code provides: Every single person who. With intent to defraud, presents for payment to any school district any false or fraudulent claim, is guilty of a felony punishable by fine and /or imprisonment.

This form is provided pursuant to Government Code Section 910.4 and shall be used by any person presenting a claim to the District under Government Code Section 900 et seq. If additional space is needed for any of the required information, please attach additional sheets.

Ref. California Government Code Sections 910-913.2

Exhibit GILROY UNIFIED SCHOOL DISTRICT

version: August 15, 2017 Gilroy, California