Claim Against The City of Tustin

(For Damages to Person or Personal Property)

PLEASE NOTE:

A. Read entire claim before filing.

B. Be sure your claim is against the City of Tustin, not another public or private entity.

C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence (Government Code § 911.2).

D. Claims for damages to real property (generally defined as land and things firmly attached to the land, such as buildings) must be filed no later than one year after the occurrence (Government Code § 911.2).

E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.

F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on his behalf (Government Code § 910.2).

G. This form is for the convenience of those desiring to present claims against the City. Claimant is advised to consult a private attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.

H. Completed claims must be submitted via this online submittal or mailed/ delivered to the City of Tustin, City Clerk’s Office, 300 Centennial Way, Tustin, California 92780.

1. Name and Mailing address of the Claimant:

Claimant Contact

Home/ Cell Telephone *

Work Telephone *

2. Notices: Select either e-mail or mailing address below to which the person presenting the claim desires notices to be sent:

E-mail address to which the person presenting the claim desires notices to be sent:

Mailing address to which the person presenting the claim desires notices to be sent:

Phone Number

3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.

Date of Occurrence *

Time of Occurrence *

Location of Occurrence *

Circumstances giving rise to this claim

4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.

5. The name or names of the City of Tustin employee or employees causing the injury, damage, or loss, if known.

6. Specify what particular act/omission on the part of City of Tustin officers or employees you claim caused the damage/injury.

7. Were police on scene?

Yes

8. Was a police report filed?

Yes

If YES, please provide Police Report Number

9. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury, damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of the amount claimed (include copies of all bills, invoices, estimates, etc.)

If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case. A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP § 86.)

Limited Civil Case

Unlimited Civil Case

You are required to provide the information requested above in order to comply with Government Code §910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the City of Tustin requests that you answer the following questions.

10. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim arises

11. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone number of any doctors or hospitals providing treatment

If applicable, please attach any medical bills or reports or similar documents supporting your claim.

12. If the claim relates to an automobile accident

Claimant(s) Auto Ins. Co.

Telephone

Address

Policy Information

Insurance Broker/ Agent

Insurance Policy Number

Telephone & Address

Vehicle Information

Claimant's Veh. Lic. No.

Vehicle Make/ Year

Claimant's License Information

Claimant's Drivers Lic. No.

Expiration

If applicable, please attach any repair bills, estimates or similar documents supporting your claim.

Upload Supporting Document(s)

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READ CAREFULLY

For all accident claims, place on following diagram name of streets, including North, East, South, and West; indicate place of accident by “X” and by showing house numbers or distances to street corners. If City/Agency Vehicle was involved, designate by letter “A" location of City/Agency Vehicle when you first saw it, and by “B” location of yourself or your vehicle when you first saw City/Agency Vehicle; location of City/Agency vehicle at time of accident by “A-1" and location of yourself or your vehicle at the time of the accident by “B-1" and the point of impact by “X.”

NOTE: If diagrams below do not fit the situation, attach hereto a proper diagram signed by claimant.

Yes - the diagram below fits my situation.

No - please see the attached proper diagram.

Street Sketch

Select a brush color: Font Color

Select a stroke width:

Upload Proper Diagram File(s)

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I acknowledge that the information provided is complete, true and accurate.

Yes

If you are submitting the claim on behalf of claimant, please state relationship. For example, insurance carrier, legal counsel or business.

Relation to Claimant

Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City of Tustin may seek to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good faith and with reasonable cause.

Sign Here

First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

You will be provided with a Receipt upon submission and will be asked to download a copy of your claim submittal. Please make sure to download, print or save this document as you may be required to submit Proof of Submittal during the claim review process. You will also be emailed a copy of this information. If you do not receive an email confirmation, please submit again as your claim may have not been properly submitted.