CLAIM FOR DAMAGES FORM - City of Cheney

CLAIM FOR DAMAGES FORMDate Claim Form Received by Member ___________________________________________MEMBER CITY/ORGANIZATION: CITY OF CHENEY, WASHINGTON, 609 2 ND Street, Cheney, WA 99004Please take note that (claimant’s name) __________________________________________________________________________,who currently resides at _______________________________________________________________________________________with a mailing address (if different from above) of __________________________________________________________________home phone # ______________________, work phone # ______________________, cell phone #____________________________at and who resided at ___________________________________________________at the time of the occurrence and whose date ofbirth is____________ is claiming damages against CITY OF CHENEY in the sum of $________________ arising out of thefollowing circumstances listed below.DATE OF OCCURRENCE: ________________________________TIME: ________________________LOCATION OF OCCURRENCE: _____________________________________________________________________________DESCRIPTION:1. Describe the conduct and circumstance that brought about the injury or damage. Also describe the injury or damage_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (attach an extra sheet for additional information, if needed)2. Provide a list of witnesses, if applicable, to the occurrence including names, addresses, and phone numbers.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. Attach copies of all documentation relating to expenses, injuries, losses, and/or estimates for repair.4. Have you submitted a claim for damages to your insurance company? _____Yes _____ NoIf so, please provide the name of the insurance company: _____________________________________________________and the policy #: _________________________________* * ADDITIONAL INFORMATION REQUIRED FOR AUTOMOBILE CLAIMS ONLY * *License Plate # ___________________Driver License # ___________________________________Type Auto: __________ _________________ ______________________________(year) (make) (model)DRIVER: _______________________________________ OWNER: ______________________________________Address: _______________________________________ Address: ___________________________________________________________________________________________________________________Phone#: _______________________________________ Phone#: ______________________________________Passengers:Name: _______________________________________ Name: ______________________________________Address: _______________________________________ Address: ___________________________________________________________________________________________________________________Claims should be submitted to the City of Cheney City clerk at the address stated above. Business hours are Monday through Friday,8:00 a.m. – 5:00 p.m., closed on weekends and official state holidays.2

Form must be signed and notarized – please see page three of this packet.I, ______________________________________, being first duly sworn, depose and say that I am the claimant for theabove described; that I have read the above claim, know the contents thereof and believe the same to be true.X_________________________________________State of WashingtonCounty of ______________X_________________________________________Signature of Claimant(s)I certify that I know or have satisfactory evidence that ________________________ is the person who appeared beforeme, and said person acknowledged that (he/she) signed this instrument and acknowledged it to be (his/her) free andvoluntary act for the uses and purposes mentioned in the instrument.Dated: _____________________________________________________________________Signature_______________________________________________TitleMy appointment expires ________________3