Claim For Damages printable pdf download

CLAIM FOR DAMAGES

This Claim Form is provided solely as an accommodation to claimant; therefore, Kitsap County

makes no representations as to its legal sufficiency. County Employees do not have authority

to render advice regarding the completion of this form, the sufficiency of the response, or to

advise a claimant on any other legal issue. Kitsap County expressly disclaims responsibility

for any such advice or review. Responsibility for complying with all requirements of state law

and county code rests solely with the claimant. (If additional space is needed to answer any

items, attach additional sheets and specify the corresponding item number).

File completed and notarized claim with:

CLERK OF THE BOARD OF COUNTY COMMISSIONERS

KITSAP COUNTY COURTHOUSE; 614 DIVISION ST. MS-4

PORT ORCHARD, WASHINGTON 98366

_______________________________, being first duly sworn on oath, deposes and says that I am

(Print full name)

the claimant herein and believe the contents of this claim to be

true. I hereby present a claim for damages against Kitsap County, Washington:

Social Security Number (optional): ____________________

Date of Birth (mm/dd/yyyy): __________________________

My actual residence at the time of presenting and filing this claim is:

__________________________________________________________________________

• Mailing address (if different from above):

__________________________________________________________________________

____________________________________________________________________

My actual residence during the time this claim arose was (if different from above):

__________________________________________________________________________

I can be reached by telephone at ______________________

Claimant’s email address: ___________________________

The incident for which I make this claim against Kitsap County occurred on

_______________________ at ____________ am/pm (circle one)

(mm/dd/yyyy)

(time)

If the incident occurred over a period of time, date of first and last occurrences:

from _____________ at _______ am/pm to _____________ at _______am/pm

(mm/dd/yyyy)

(time)

(mm/dd/yyyy)

(time)

CLAIM FOR DAMAGES

AND AFFIDAVIT OF CLAIMANT

(General) 6/09

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Claim For Damages