Do I need a notary for the Claim for Damage or Injury?

No. The claimant signs and dates a declaration under penalty of perjury on page three; the form does not require notarization.

How do I submit the Claim for Damage or Injury?

Mail the completed form or deliver it in person to the City Clerk’s Office at 10500 Civic Center Drive, Rancho Cucamonga, CA 91730. Electronic submissions are not accepted.

What information does the claim form request?

It asks for claimant contact information, incident details, information about injuries or damage, and the amount claimed. It also requests supporting documents and, for vehicle claims, proof of insurance.

What documents should I attach to the claim?

The form requests copies of documentation such as receipts, photographs, repair estimates, and medical bills. Property damage claims should include two repair estimates; automobile accident claims should attach proof of insurance.

Rancho Cucamonga, CA · San Bernardino County

No notary required

Claim for Damage or Injury

This form lets a person submit a claim to Rancho Cucamonga for injury or property damage allegedly caused by the city or its employees.

What this form is

Use this form to report a death, personal injury, or property damage claim involving the city or its employees. The form says claims for death or personal property injury must be filed within six months of the occurrence, and claims for real property damage within one year. It asks for claimant and incident details, injury or damage information, supporting documentation, and a signature.

Who needs it

A person seeking compensation from Rancho Cucamonga for injury or property damage allegedly caused by the city or its employees should complete this form.

How to submit it

Mail the completed claim or deliver it in person to the City Clerk’s Office, 10500 Civic Center Drive, Rancho Cucamonga, CA 91730; electronic submissions are not accepted.

About notarization

No notary is required; the claimant signs and dates the declaration under penalty of perjury on page three.

How to submit this form

1
Download The Claim Form
Download the Claim for Damage or Injury PDF.
2
Complete Every Question
Provide the requested claimant, incident, injury or damage, and claim amount details. Write N/A for questions that do not apply.
3
Gather Supporting Documents
Attach relevant receipts, photographs, repair estimates, and medical bills. Include two repair estimates for property damage claims and proof of insurance for automobile accident claims.
4
Sign And Submit
Sign and date page three, then mail the form or deliver it in person to the City Clerk’s Office. Electronic submissions are not accepted.

Frequently asked questions

Do I need a notary for the Claim for Damage or Injury?: No. The claimant signs and dates a declaration under penalty of perjury on page three; the form does not require notarization.
How do I submit the Claim for Damage or Injury?: Mail the completed form or deliver it in person to the City Clerk’s Office at 10500 Civic Center Drive, Rancho Cucamonga, CA 91730. Electronic submissions are not accepted.
What information does the claim form request?: It asks for claimant contact information, incident details, information about injuries or damage, and the amount claimed. It also requests supporting documents and, for vehicle claims, proof of insurance.
What documents should I attach to the claim?: The form requests copies of documentation such as receipts, photographs, repair estimates, and medical bills. Property damage claims should include two repair estimates; automobile accident claims should attach proof of insurance.

Need something notarized?

This Claim for Damage or Injury doesn’t need a notary — but if you have another Rancho Cucamonga form that does, a commissioned online notary can help.