FORM B CITY OF DINUBA CLAIM FORM Claim Against (Name ofl Entity) Claimant' S Name Claimant' S DOB Claimant's s SS# Claimant": S Address: Address where Notices related to this Claim shall be sent, if different from above: Date of incident/accident: Date injury/ damage/ loss discovered: Location ofi incident/accident: What did entity or employee do to cause this loss, damage, or injury? (Use the back oft this form or separate sheet if necessary to answer this question in detail.) Names of the Entity's employees who caused this injury, damage, or loss (ifknown): What are Claimant' S specific injuries, damages, or losses? What amount of money is claimant seeking, or ifthe amount is in excess of$10,000, which is the appropriate court ofjurisdiction?. Note: IfSuperior and Municipal Courts are consolidated, you must represent whether it is a "limited civil case" [see Government Code 910(f)] How was this amount calculated (please itemize)? Date Signed: Signature: Ifsigned by az representative: Representative's Name Phone #. Address Relationship to Claimant PLEASE READ - IMPORTANT! Your claim must be filed within 6 months of the incident (Government code 911.2). Your claim will be forwarded to the City's Risk Manager for investigation. Following that, your claim will be either settled or denied. You will be notified by mail. If your claim is denied, you will have 6 months from date of denial to initiate an action against the city (Government code 945.6). Our hope is that you will be treated fairly. If you have any questions, please call (559) 591-5900 ext. 108.