Form Sh Ad 672 PDF Details

Navigating the complexities of submitting a claim for damages to person or property with the Los Angeles County Sheriff's Department is facilitated through the comprehensive SH AD 672 form. This essential document serves as a foundational tool for individuals seeking to file claims for any damage or injury that occurred, tying the responsibility to the Sheriff's Department. As stipulated by the form, claimants are guided through detailed instructions which underscore the importance of completing the form meticulously and submitting the original signed copy for processing. Among these instructions, the form highlights critical timelines governed by statutory deadlines—emphasizing a six-month filing window for claims related to death, injury, or damage to personal property, and a one-year period for other damages, according to Government Code Section 911.2. Moreover, it elucidates the process to be followed post-rejection of a claim, indicating the permissible timeframe for filing a court action, thereby ensuring claimants are well-informed of their legal avenues. The form further demands precise information about the incident, including when and where it occurred, details of the damage or injury, and an account of why the Sheriff's Department is deemed responsible, alongside a comprehensive listing of damages incurred. This structured approach, designed to capture all relevant details upfront, aids in the streamlined processing of claims, while also cautioning against the submission of false claims—a felony under the Penal Code Section 72. Thus, the SH AD 672 form not only serves as a practical resource for individuals pursuing claims but also embodies a critical procedural step in upholding accountability within one of the county's key law enforcement bodies.

QuestionAnswer
Form NameForm Sh Ad 672
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesfillable sheriff instructions forms los angeles, Kenneth, GOV, amazon

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LOS ANGELES COUNTY SHERIFF'S DEPARTMENT

CLAIM FOR DAMAGES TO PERSON OR PROPERTY

INSTRUCTIONS:

1.Read entire claim thoroughly.

2.Fill out the claim completely.

3.This claim form must be signed.

4.Submit original signed copy.

5.Photocopies may be made for your records.

WARNING

-Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence. (GOV. CODE SECTION 911.2)

-All other claims for damages must be filed no later than one year after the occurrence.

(GOV. CODE SECTION 911.2)

- Subject to certain exception, you have only six months from the date of written notice of rejection of your claim to file a court action. (GOV. CODE SECTION 945.6)

-If written notice of rejection of your claim is not given, you have 2 years from accrual of the cause of the action to file a court action. (GOV. CODE SECTION 945.6)

1. WHEN AND WHERE DID DAMAGE OR INJURY OCCUR?

DATE:

TIME:

STREET ADDRESS OR LOCATION:

CITY:

ZIP:

 

 

 

 

 

2. NAME(S) OF SHERIFF PERSONNEL INVOLVED:

STATION / FACILITY:

NAME:

NAME:

STATION / FACILITY:

 

TIME STAMP HERE

FOR OFFICE USE ONLY

15.WERE THE PARAMEDICS CALLED?

16.DID THE CLAIMANT VISIT A PHYSICIAN? PHYSICIAN'S NAME:

ADDRESS/(PHONE):

DATE OF VISIT:

3.DESCRIBE IN DETAIL HOW DAMAGE OR INJURY OCCURRED: (Use attachments if necessary)

4. WHY DO YOU CLAIM THE SHERIFF'S DEPARTMENT IS RESPONSIBLE?

5.LIST DAMAGES INCURRED TO DATE (Attach Copy of Receipts & Repair Estimates)

6.SHERIFF'S DEPARTMENT FILE OR REPORT#

7. NAME OF CLAIMANT (Print Clearly)

8. DRIVER'S LICENSE OR I.D. #

 

 

 

 

 

9. DATE OF BIRTH

10. SOCIAL SECURITY

11. Booking Number (if applicable)

 

#

 

 

 

 

 

 

 

 

 

 

12. CORRESPONDENCE ADDRESS - (STREET, CITY, STATE, ZIP)

 

,

 

 

,

,

 

 

 

 

 

13. HOME PHONE (or phone you can be contacted at)

 

 

14. BUSINESS PHONE

 

( )

 

 

 

( )

 

 

 

 

 

 

 

17.WITNESS TO DAMAGE OR INJURY? NAME:

ADDRESS:

CITY/PHONE:

NAME:

ADDRESS:

CITY/PHONE:

TOTAL DAMAGES TO DATE

$

TOTAL ESTIMATED DAMAGES

$

THIS CLAIM MUST BE SIGNED

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

18. SIGNATURE OF CLAIMANT OR PERSON FILING ON HIS/HER BEHALF:

19. PRINT OR TYPE NAME

DATE

 

 

 

 

 

 

 

 

Deliver or mail to Executive Officer, Board of Supervisors, County of Los Angeles, Room 383, Kenneth Hahn Hall of Administration, 500 W. Temple St. LA, CA 90012

SH-AD-672

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For you to complete this document, make sure that you provide the right information in each and every blank field:

1. First, when filling out the Kenneth, begin with the page with the next fields:

Guidelines on how to fill in applicable step 1

2. The subsequent part is to complete the next few fields: SHERIFFS DEPARTMENT FILE OR REPORT, NAME OF CLAIMANT Print Clearly, DRIVERS LICENSE OR ID, NAME, ADDRESS, CITYPHONE, NAME, ADDRESS, DATE OF BIRTH SOCIAL SECURITY, Booking Number if applicable, CITYPHONE, CORRESPONDENCE ADDRESS STREET, HOME PHONE or phone you can be, BUSINESS PHONE, and TOTAL DAMAGES TO DATE.

DATE OF BIRTH SOCIAL SECURITY, TOTAL DAMAGES TO DATE, and NAME OF CLAIMANT Print Clearly of applicable

As for DATE OF BIRTH SOCIAL SECURITY and TOTAL DAMAGES TO DATE, be sure you don't make any mistakes in this current part. Those two could be the key ones in the form.

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