Atwater, CA · Merced County
Claim Form
Claimants use this form to describe an incident, injury, damage, or loss and state the amount of money they are seeking from an entity.
What this form is
The form records a claim against an entity, including what happened, when and where it occurred, and any injuries, damages, or losses. It asks for the claimant’s contact information, details about the entity or employee involved, the amount sought and how it was calculated, and a signature. Use extra pages if needed to answer questions in detail.
Who needs it
A claimant seeking money for an injury, damage, or loss allegedly caused by an entity or its employee can use 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 form is signed without a notary; the claimant or representative signs and dates it, and no notarized attachment or sworn step is listed.
How to submit this form
- 1
Download The Form
Download the Claim Form.
- 2
Complete The Form
Fill in the claimant and incident details, describe the loss, and state the amount sought and how it was calculated.
- 3
Gather Extra Pages
Use the back of the form or a separate sheet if you need more space for detailed answers.
- 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 details, incident dates and location, what caused the loss, injuries or damages, the amount sought and its calculation, and a signature.
- Do I need a notary for the Claim Form?
- No. The claimant or representative signs and dates this form; it does not list a notarized attachment or sworn step.
- How do I submit the Claim Form?
- The form does not give submission instructions. Submit it to the city department named on the form; check the city website for current contact details.