Placentia, CA · Orange County
Claim Form for Damages
Claimants use this form to report a claim for damages to the City of Placentia and provide details about the incident and losses.
What this form is
Use this form to submit a claim for damages to the City of Placentia. It asks for claimant and incident information, details about the claimed damage or injury, and the amount and basis of the claim. Property damage claims must include two bona fide repair estimates, and the form must be signed by the claimant or a representative.
Who needs it
A person seeking damages from the City of Placentia should complete and submit this form with the required information and supporting documents.
How to submit it
Submit the original claim form by mail or in person to City of Placentia, Attn: City Clerk, 401 E. Chapman Avenue, Placentia, CA 92870.
About notarization
This form is signed without a notary; the claimant certifies under penalty of perjury that the information and attachments are true and correct.
How to submit this form
- 1
Download the Form
Download the City of Placentia Claim Form for Damages.
- 2
Complete the Form
Fill in all mandatory fields and provide the requested claimant, incident, damage, and claim amount details.
- 3
Gather Attachments
Attach supporting bills, invoices, or estimates; property damage claims must include two bona fide repair estimates.
- 4
Sign and Submit
Sign and date the form, then mail or deliver the original to the City Clerk at the address listed on the form.
Frequently asked questions
- Do I need a notary for the Placentia Claim Form for Damages?
- No. The form is signed without a notary, but the claimant certifies under penalty of perjury that the information and attachments are true and correct.
- How do I submit the Placentia Claim Form for Damages?
- Submit the original by mail or in person to the City Clerk at City Hall, 401 E. Chapman Avenue, Placentia, CA 92870.
- What should I attach to a property damage claim?
- The form requires two bona fide repair estimates for claims involving property damage. It also asks for copies of bills, invoices, repair estimates, or other support for the claimed amounts.
- What information does the claim form ask for?
- It asks for claimant details, the incident date, time and location, how the damage or injury occurred, the claimed losses, and information about witnesses or treatment, if applicable.