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Lemoore Union HSD |  E  3320  Business and Noninstructional Operations

Claims And Actions Against The District   

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CLAIM FORM

TO: Mark Howard

Lemoore Union High School District

5 Powell Avenue

Lemoore, CA 93245

1. Claims for death, or for injury to person or to personal property must be presented to the District not later than six (6) months after the occurrence (Govt. Code, Section 911.2), including those claims detailed in Board Policy 3320 and Administrative Regulation 3320.

2. Claims for damages to real property or for breach of contract must be presented not later than one year after the occurrence (Govt. Code, Section 911.2)

3. Please carefully read the Lemoore Union High School District Board Policy 3320 and Administrative Regulation 3320 regarding the presentation of a claim.

__________________________________________________________________________________________

Name of Claimant DOB Phone No.

__________________________________________________________________________________________

Address City Zip

Name and Address where notices shall be sent: ___________________________________________________

State the DATE the injury or damage occurred: __________________________________________________

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: (Include names of employees, if known)

__________________________________________________________________________________________

__________________________________________________________________________________________

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 of computation of the amount claimed; attach estimates or invoices, if possible. (If amount claimed exceeds $10,000, no dollar amount shall be stated).

___________________________________________________________ $_________________

___________________________________________________________ $_________________

Total Amount Claimed $_________________

If total amount claimed exceeds $10,000, is this a Limited Civil case? Yes ______ No ______

NAMES and addresses of witnesses, doctors and hospitals:

__________________________________________________________________________________________

__________________________________________________________________________________________

DATE: ________________________ ____________________________________________

Signature of Claimant

NOTICE: Section 72 of the California Penal Code provides that every 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.

Exhibit LEMOORE UNION HIGH SCHOOL DISTRICT

version: August 9, 2018 Lemoore, California