eCopy, Inc. - Shasta College

~Shasta.CollegeReceivedMAR 2 g 2013Shasta CollegeAdministrative Services123CLAIM FOR INJURY OR DAMAGEClaims for death, injury to person, or to personal property must be filed not later than six (6) months after the" occurrence. Claims for .damages to real property must be filed not later than one year after the occurrence.(Government Code Section 911.2)Name of ClaimantMailing AddressCity, State, ZipPhone No.Date of injury/damage(Please print or type)••• l_ _____ Date of Birth:----......12=/..-11=/...:.:12=-------- Time of Day 12:45pm - estLocation of accident/damage Parking lot west of 2200 Building. Main Campus .Describe circumstances of damage or how injury occurred (use back of form if more room needed):Refer to security. report - dated 12/11/12 by Shasta College security. Pulled into parking spotand bumper hag a piece of rebar sticking up- this caught on my bumper and pulled jt off.Explain what action by Shasta College or its employees caused the damage or injury:Maint. Rebar sticking up on parking bumper caused damage. after my accident this was fixed.Amount you are claiming (attach estimates or bills, if possible):~R~e~p=ai~r~a~s~d~e~ta~il~e=d~o~n~a~ti~a~c~he~d~e~&~im~a=t~e~----------------------$~75~0~·~92~.----------------------------------~-------------------------$---------------------------------------------------------------$ $ __________ ___Total ClaimIf total amount claimed exceeds $10,000, is this a Limited Civil case?Names and addresses of witnesses, doctors and hospitals (if applicable):Yes __ No __ICRIMINAL PENALTY FOR PRESENTINGd/ijAUDULENT CLAIM OR MAKING FALSE STATEMENTS: Everyperson who, with intent to defraud, presenis[.~,f'paymentany false or fraudulent claim against a public entity may beguilty of a felony punishable by fine and/or itn'/!irisonment. (California Penal Code, Section 72)Please return completed form toShasta College, Attn: Administrative ServicesP.O. Box 496006, Redding, CA 96049~6006