Form Center

2. Instructions
   (Please read carefully): Claims related to injury to person or damage to personal property must be presented to the City within six (6) months from the date of loss. Claims related to any other loss must be presented not later than one (1) year from the date of loss. Answer all items fully and to the best of your knowledge and information. Failure to do so may result in your claim being found insufficient. If more space is needed to provide requested information, please attach additional pages identifying paragraph(s) being answered. Any questions about claim submissions, can be directed to 831-899-6703.
4. Please Select Which Agency you are filing the Claim Against*

   1. City of Seaside
   2. Seaside County Sanitation District
6. Claimant's Name*
8. Date of Birth*
   Date of Birth

   Date of Birth
10. Home Phone Number*
11. Daytime Phone Number*
13. Claimant's Mailing Address
15. Street Number and Name*
17. Apartment Number
19. City*
20. State*
21. Zip Code*
23. Date and Time of Loss
    Date and Time of Loss

    Date and Time of Loss
25. Location of Loss*
27. Description of incident/accident which caused you to make this claim.*
29. What specific injury, damages or other losses did you incur?
31. What amount of money are you seeking to recover?*

    1. The amount claimed totals less than $10,000.
    2. The amount claimed is more than $10,000 but not over $25,000.
    3. The amount claimed is more than $25,000; jurisdiction rests in Superior Court.
33. Amount Claimed*
35. How was this amount calculated? *
37. What is your basis for claiming that the City or City employee(s) are the cause of your injury, damages or loss? *
39. What are the name(s) of the City employee(s) whom you allege caused your injury, damages or loss, if known? *
41. Name, address and phone number of any witness who can substantiate your claim.
43. Any additional information that you believe might be helpful to the City in considering this claim.
45. May we direct all notices and communications with regard to this claim to the Claimant shown above?*

    1. Yes
    2. No
47. Secondary Name*
49. Relationship*
51. Street Address*
53. City*
54. State*
55. Zip Code*
57. Daytime Phone Number
58. Home Phone*
60. Confirmation
    I/We, the undersigned, declare under penalty of perjury that I/We have read the foregoing claim for damages and know the contents thereof, that the same is true of My/Our own knowledge and belief, save and except as to those matters wherein stated on information and belief, and as to them I/We believe to be true.
    
    (Note: If someone files the claim on behalf of the claimant, the person making the claim on behalf of the claimant should sign below.)
62. Claimant Signature*
63. Date Signed*
    Date Signed
65. Claimant Signature
66. Date Signed
    Date Signed
68. Fraud Warning
    WARNING: PRESENTATION FOR ALLOWANCE OR PAYMENT OF A FALSE OR FRAUDULENT CLAIM, WITH INTENT TO DEFRAUD, IS A CRIME PUNISHABLE AS A FELONY UNDER CALIFORNIA PENAL CODE, SECTION 72, AND INSURANCE CODE, SECTION 1871.1.
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field