Orange — Claim for Money or Damages

Orange — Claim for Money or Damages¶

Source: https://www.ocsheriff.gov/sites/ocsd/files/2026-09/Revised%20Claim%20Form%202024.pdf

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Received by _____________ via: □ Mail □ Over the Counter □ Pony Mail Other *** COB USE ONLY*** CLAIM FOR MONEY OR DAMAGES □ AGAINST THE COUNTY OF ORANGE (Pursuant to Govt. Code section 910 et seq.)

Completed and signed forms must be mailed or delivered to: Clerk of the Board of Supervisors 400 W. Civic Center Drive, 6th Floor Santa Ana, CA 92701

INSTRUCTIONS: Claims related to personal injury or damage to personal property must be presented within six (6) months from the date of loss. Claims related to any other loss must be presented not later than one (1) year from the date of loss. (See Government Code Section 911.2) Please answer all items fully and to the best of your ability. Failure to do so may be grounds for deeming your claim insufficient. If more space is needed, please attach additional pages.

CLAIMANT INFORMATION

Claimant’s Name: __________________________________ 2. Date of Birth: _____________
Claimant’s Address: _____________________________________________________________ Street (or P.O. Box) City State Zip Code
Phone Number: ___________________ ____________________ ______________________ Home Work Other
Name and address where correspondence should be sent (if different from above):

Name Street (or P.O. Box) City State Zip Code

CLAIM INFORMATION
Exact date (including year) of the accident/incident/loss: ________________________________
Exact location of the accident/incident/loss (Be as specific as possible; Example: On the southeast corner of 6th and Broadway in the City of Santa Ana):
Describe the circumstances of how the accident/incident/loss occurred including the reason you believe the County of Orange is liable for your damages:

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Jail Booking Number: _______________ Police Agency/Report Number: ________________
Describe the damage/injury/loss incurred so far as is known as of the time of this claim:

Name(s) of County employee(s) causing damage/injury/loss, if known: ___________________

License number of County vehicle (if applicable): ____________________________________
Name, address and phone number of any and all witnesses known: _____________________

Any additional information that may assist us in evaluating your claim:__________________

DAMAGES CLAIMED

a. If the amount claimed is less than $10,000: Amount claimed to present: $___________________________ Estimated amount of any prospective damage/injury/loss: $___________________________ TOTAL AMOUNT CLAIMED: $___________________________ b. If the amount claimed exceeds $10,000, would the case be a limited civil case ($35,000 or less)? Check one: Yes ______ No ______

c. Basis of computation of the amount of damages (Please attach any estimates and/or receipts): ___________________________________________________________________

WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM (PENAL CODE § 72)

I have read the matters and statements in the above claim and I know the same to be true of my own knowledge, except as to those matters stated upon information and belief and as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct.

Signature of Claimant/Claimant’s Representative Date

THIS CLAIM FORM MUST BE SIGNED!!

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