Who can present a claim using this form?

The document says a claim may be presented by the claimant or by a person acting on the claimant’s behalf.

What information does the Claim Form request?

It asks for claimant and notice-contact details, event date and place, a description of the loss, known employees involved, and the amount claimed and its calculation.

How do I submit the Claim Form?

Return the completed form to the City of Placerville, City Clerk, at 3101 Center Street, Placerville, CA 95667.

Do I need a notary for the Claim Form?

No. The form is signed and dated without a notary, and it lists no sworn or notarized attachment or related step.

Placerville, CA · El Dorado County

No notary required

Claim Form

The City of Placerville Claim Form lets a claimant or someone acting on their behalf present a claim to the city and describe the related loss.

What this form is

A claimant or a person acting on the claimant’s behalf can use this form to present a claim to the City of Placerville. It asks for claimant and notice-contact details, the date and place of the event, a description of the loss, known public employees involved, and the amount claimed with its calculation. The form says any written claim meeting its stated requirements may be substituted.

Who needs it

A claimant, or someone acting on the claimant’s behalf, may use this form to present a claim to the City of Placerville.

How to submit it

Return the completed form to the City of Placerville, City Clerk, 3101 Center Street, Placerville, CA 95667.

About notarization

This form is signed and dated without a notary; it lists no sworn or notarized attachment or related step.

How to submit this form

1
Download The Form
Download the City of Placerville Claim Form PDF.
2
Complete The Form
Answer all questions, print legibly, and use the back if more space is needed.
3
Review Your Claim
Include the requested claimant, event, loss, employee, and amount information.
4
Sign And Date
Sign and date the form, and provide your relation to the claimant if applicable.
5
Return The Form
Send it to the City Clerk at 3101 Center Street, Placerville, CA 95667.

Frequently asked questions

Who can present a claim using this form?: The document says a claim may be presented by the claimant or by a person acting on the claimant’s behalf.
What information does the Claim Form request?: It asks for claimant and notice-contact details, event date and place, a description of the loss, known employees involved, and the amount claimed and its calculation.
How do I submit the Claim Form?: Return the completed form to the City of Placerville, City Clerk, at 3101 Center Street, Placerville, CA 95667.
Do I need a notary for the Claim Form?: No. The form is signed and dated without a notary, and it lists no sworn or notarized attachment or related step.

Need something notarized?

This Claim Form doesn’t need a notary — but if you have another Placerville form that does, a commissioned online notary can help.