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%'~~,,,~ '+'~.' CE~UNTY OF BUTTE, STATE OF CALIFORNIA
•'•.^.?+'•••.,,,,,,,..~~•'~~~'•'~• Resolution No. 03-064
RESOLUTION OF THE COUNTY OF BUTTE ADOPTING A FORM FOR FILING A
CLAIM FOR DAMAGES AGAINST THE COUNTY OF BUTTE
WHEREAS, the "California Government Tort Claims Act", as set forth in Government
Code Section 900 et seq. (hereinafter "the Act"), requires the governing body of a public entity
to provide forms specifying information to be contained in claims against the public entity; and
WHEREAS, the person presenting a claim shall use the public entity's claim form in
order to comply with Sections 910 and 910.2 of the Government Code; and
WHEREAS, a claim may be returned to the person if it was not presented using the
public entity's form, however, the claim maybe resubmitted using the appropriate form.
NOW, THEREFORE, BE IT RESOLVED, that the Butte County Board of
Supervisors adopts the attached form titled "County of Butte Claim for Damages to Person or
Property" as the official form to be used by persons wishing to file a claim for damages against
the County.
PASSED AND ADOPTED by the Butte County Board of Supervisors this 22°`~ day of
April 2003 by the following vote:
AYES: Supervisors Dolan, Houx, Josiassen, Yamaguchi and Chair Beeler
NOES: None
ABSENT: None
NOT VOTING: None
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R. J. BEELER, Chair
ATTEST:
PAUL MCINTOSH, Chief Administrative Officer
And Clerk of the Board of Supervisors
Deputy
FILE WITH:
Butte County Risk Management COUNTY OF BUTTE RESERVE FOR FILING STAMP
3-A County Center Drive CLAIM FOR DAMAGES
Oroville, CA 95965-3334 TO PERSON OR PROPERTY CLAIM NO.
INSTRUCTIONS
1. Read entire claim form before filing.
2. See reverse side for diagram upon which to locate place of accident.
3. This claim form must be signed on the reverse side at the bottom.
4. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
Name of Claimant Date of Birth of Claimant
Home Address of Claimant City, State and Zip Code Home Telephone Number
Mailing Address of Claimant City, State and Zip Code Occuparion of Claimant
Business Address of Claimant City, State and Zip Code Business Telephone Number
Give address and telephone number to which you desire notices or communications to be sent Claimant's Social Security Number
regarding this claim:
When did DAMAGE or INJURY occur? Names of any county employees involved in INJURY or DAMAGE
Date Time
If claim is for Equitable Indemnity, give date
claimant served with the complaint:
Date
Where did DAMAGE or INJURY occur? Describe fully and locate on diagram on reverse side of this sheet. Where appropriate, give
street names, addresses and measurements from landmarks:
Describe in detail how the DAMAGE or INJURY occurred.
Why do you claim the County is responsible?
Describe in detail each INJURY or DAMAGE.
(OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE
The amount claimed, as of the date of presentation of this claim, is computed as follows:
Damaees incurred to date (exact): Estimated prospective damages as far as lozown:
Damage to property. ....................... $ Future expenses for medical and hospital care.......... $
.............
Expenses for medical and hospital care ...... $ Future loss of earnings ..............................................
Other ros ective s ecial damages ........................... $
Loss of earnings .......................................... $ P P P .... $
Special damages for .................................... $ Prospective general damages ................................
Total estimate prospective damages ............. $
General damages ........................................... $
Total damages incurred to date ..................... $
Total amount claimed as of date of presentation of this claim ................. $
Was damage and/or injury investigated by police? If so, City, County or State?
Where paramedics or ambulance called? If so, name provider ambulance
If injured, state date, time, name and address of doctor of your first visit
WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons lmown to have information:
Address Phone
Name Address Phone
Name Address Phone
Name
DOCTORS and HOSPITALS: Date Hospitalized
Hospital
Address _
Date of Treatment
Doctor Address
Address _
Date of Treatment_
Doctor
READ CAREFULLY
For all accident claims place on following diagram names of streets, including North, East, South and West; indicate place of accident
by "X" and by showing house numbers or distances to street comers. If County vehicle was involved, designate by letter "A" location
of County vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw County vehicle; location
of County 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 diagram below does not fit the situation, attach hereto a proper diagram signed by claimant.
CiIRB
PARKWAY
1 SIDEWALK
Ci JRB
Signature of Claimant or person filing on his behalf Type/Print Name: Date:
giving relationship to Claimant:
NOTE: CLAIMS MUST BE FILED WITH BUTTE COUNTY'S RISK MANAGEMENT'S OFFICE (Gov. Code Sec. 915a).
Presentation of a false claim is a felony (Pen. code Sec. 721•
Ol /07/03
2Claim for Damages