Firebaugh, CA · Fresno County
Claim Form
The Claim Form lets a claimant describe an incident, injury, damage, or loss and request money from the entity named on the form.
What this form is
Use this form to make a claim against the entity identified by name. It asks for claimant and notice addresses, incident and discovery dates, location, details of what caused the loss, known employee names, specific injuries or damages, and the amount sought with an itemized calculation. If more detail is needed, the form says to use its back or a separate sheet.
Who needs it
A person seeking money for an injury, damage, or loss allegedly caused by the entity or one of its employees can complete this form.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This claim form is signed and dated without a notary; it lists no notarized or sworn attachment, so the claimant or representative just signs and dates it.
How to submit this form
- 1
Download The Form
Download the Claim Form PDF.
- 2
Complete Claimant And Incident Details
Fill in the claimant information, incident dates and location, what caused the loss, and the injuries or damages.
- 3
Itemize The Amount Sought
State the amount sought and explain how it was calculated; use the back of the form or a separate sheet if needed.
- 4
Sign And Submit
Date and sign the form, then submit it to the city department named on the form.
Frequently asked questions
- What information does the Claim Form ask for?
- It asks for claimant and notice addresses, incident details and dates, injuries or losses, the amount sought, and an itemized calculation.
- Do I need a notary for the Claim Form?
- No. This form is signed and dated without a notary, and it lists no notarized or sworn attachment.
- How do I submit the Claim Form?
- Submit it to the city department named on the form; check the city website for current contact details.