Pinole, CA · Contra Costa County
Claim Presented to the City
This claim form lets a person seek compensation from the City of Pinole for injury, damage, or loss allegedly caused by the city.
What this form is
Use this form to present a claim to the City of Pinole for injury, damage, or loss. It asks for claimant and incident details, an explanation of why the city is responsible, the claimed amount, and supporting documentation. Complete it with the requested information, attach relevant documents, and sign it before submitting it to the City Clerk.
Who needs it
A person claiming injury, damage, or loss allegedly caused by the City of Pinole should complete and submit this form.
How to submit it
Mail or personally deliver the completed claim and related documentation to Heather Bell-Spears, City Clerk, City of Pinole, 2131 Pear Street, Pinole, CA 94564. The form lists personal service during regular city business hours, Monday through Thursday, excluding city holidays.
About notarization
This document is signed by the claimant or representative without a notary; the form requests supporting documentation, but does not say that any attachment must be notarized or sworn.
How to submit this form
- 1
Download the Claim Form
Download the City of Pinole claim form PDF.
- 2
Complete the Form
Type or print clearly, provide the requested claimant and incident information, and explain the claimed loss and amount.
- 3
Gather Supporting Documents
Attach related documentation, such as bills, receipts, or cost estimates, and add pages if needed.
- 4
Sign and Submit
Have the claimant or representative sign and date the form, then mail or personally deliver it with related documentation to the City Clerk.
Frequently asked questions
- Do I need a notary for the City of Pinole claim form?
- No. The claimant or representative signs the form without a notary. Supporting documentation may be attached, but the form does not require notarized or sworn attachments.
- How do I submit the claim form?
- Mail or personally deliver the completed form and related documentation to the City Clerk at 2131 Pear Street, Pinole, CA 94564. Personal service is listed for Monday through Thursday during regular city business hours, excluding city holidays.
- What information does the claim form request?
- It requests claimant and contact information, incident date and location, a description of what happened and why the city is responsible, the claimed amount, supporting documentation, and a signature.
- What supporting documents can I attach?
- The instructions mention bills, payment receipts, and cost estimates as examples of supporting documentation. They say private bank, credit card, or other information may be redacted.