Domestic Violence Form – Fill Out and Use This PDF

COUNTY OF RIVERSIDE

CLAIM FOR DAMAGES TO PERSON OR PROPERTY

INSTRUCTIONS:

OFFICE USE ONLY

1.

Read claim thoroughly.

2.

Fill out claim as indicated; attach additional information if necessary.

3.

This office needs the original

completed claim form and clear readable copies

of attachments (if any) if originals are not available.

4.

This claim form must be signed.

DELIVER OR U.S. MAIL TO: CLERK OF THE BOARD OF SUPERVISORS

ATTN: CLAIMS DIVISION

P . O . BOX 1628, 4080 LEMON ST, 1S T FL.

RIVERSIDE, CA . 92502 - 1628

(951) 955 - 1060

TIME STAMP HERE

1. FULL NAME OF CLAIMANT

8. WHY DO YOU CLAIM THE COUNTY IS RESPONSIBLE?

2. MAILING ADDRESS

(STREET/P O BOX)

CITY

STATE

ZIP CODE

HOME TELEPHONE

BUSINESS TELEPHONE

9. NAMES OF ANY COUNTY EMPLOYEES (AND THEIR DEPARTMENTS) INVOLVED IN

INJURY OR DAMAGE (IF APPLICABLE).

(

)

(

)

3. WHEN DID DAMAGE OR INJURY OCCUR (PLEASE BE EXACT)

NAME:

DEPARTMENT:

4. WHERE DID DAMAGE OR INJURY OCCUR?

NAME:

DEPARTMENT:

STREET

CITY

STATE

ZIP CODE

10. WITNESSESS TO DAMAGE OR INJURY: LIST ALL PERSONS AND ADDRESSES OF

PERSONS KNOWN TO HAVE INFORMATION:

5. DESCRIBE IN DETAIL HOW DAMAGE OR INJURY OCCURRED:

NAME

PHONE

ADDRESS

NAME

PHONE

ADDRESS

NAME

PHONE

ADDRESS

11. LIST DAMAGES INCURRED TO DATE (attach copies of receipts or repair estimates)

6. WERE POLICE OR PARAMEDICS CALLED?

฀ YES

฀ NO

7. IF PHYSICIAN/HOSPITAL WAS VISITED DUE TO INJURY, INCLUDE DATE OF FIRST VISIT

AND HOSPITAL’S NAME, ADDRESS AND PHONE NUMBER:

DATE OF FIRST VISIT

PHYSICIAN’S/HOSPITAL’S NAME

PHYSICIAN’S/HOSPITAL’S ADDRESS

PHONE:

TOTAL DAMAGES TO DATE

TOTAL ESTIMATED PROSPECTIVE DAMAGES

(

)

$_______________________

$_______________________________________

THIS CLAIM MUST BE SIGNED TO BE VALID.

NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (PENAL CODE SECTION 72.)

SIGNATURE

RELATIONSHIP TO CLAIMANT