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Body Ornamentation Across Cultures

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CLAIM AGAINST THE CITY OF SAN DIEGO
(FOR DAMAGES TO PERSONS OR PERSONAL PROPERTY)

Present claim by personal delivery or mail to the City of San Diego, Risk Management Dept., 1200 Third Ave., Suite 1000, San Diego, CA 92101. Received via:  U.S. Mail  Inter-Office Mail  Over-the-Counter TIME STAMP

FILE No. ________________

TO THE HONORABLE MAYOR AND CITY COUNCIL, the City of San Diego, California I, _______________________, hereby make a claim against the City of San Diego and make the following statements in support of the claim: 1. CLAIMANT INFORMATION a. b. Claimant’s Name: ______________________________________________________ Post Office Address of Claimant: _____________________________________ _____________________________________________________________________ (CITY) (STATE) (ZIP) c. d. e. Claimant’s Home Phone No.: ______________________________________ Claimant’s Business Phone No.: ___________________________________ Post Office address to which the person presenting the claim desires notices to be sent, if different than above: ____________________________________________________ _______________________________________________________________________ f. g. h. 2. Social Security No.: ______________________________ Date of Birth: ___________________________________ Driver’s License No.: _____________________________

CIRCUMSTANCES GIVING RISE TO THE CLAIM a. b. c. Date of the occurrence or transaction which gave rise to the claim: ________________ Time of the occurrence or transaction which gave rise to the claim: ________________ Place of occurrence or transaction (please be specific): __________________________ _______________________________________________________________________ _______________________________________________________________________

RM-9 (Rev. 12-10) This information is available in alternative formats upon request

d.

Other circumstances of the occurrence or transaction giving rise to the claim: ______ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

3.

DESCRIPTION OF CLAIM a. General description of the indebtedness, obligation, injury, damage or loss incurred: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ b. The name or names of the public employee or employees causing the claimant’s injury, damage, or loss, if known, are: ___________________________________________ _____________________________________________________________________ _____________________________________________________________________ Damages [please choose one]:  The amount claimed is less than $10,000. The amount of the claim as of the date of this claim is $___________. This figure is based on the following: ________________________________________________ ____________________________________________________________________  The amount claimed is more than $10,000. Please state if the claim would be a limited civil case 1. _______________________ d. Please provide any additional information that might be helpful in considering your claim, including names of witnesses, treating physicians, and hospitals: _________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Please attach and/or provide any additional information that may be helpful in considering your claim including proof of damages such as invoices, receipts, and estimates.

c.

e.

WARNING: It is a criminal offense to file a false claim (Cal. Penal Code § 72). I have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters stated upon information or belief and as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. Dated: ______________________ ___________________________________________ Signature of Claimant or Person Acting On Behalf of Claimant

1

Limited civil cases are discussed in California Code of Civil Procedure § 85.

RM-9 (Rev. 12-10) This information is available in alternative formats upon request

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