Gilroy USD | E 3320 Business and Noninstructional Operations
Claims And Actions Against The District
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