Yolo — Claim for Damages

Source: https://yolocountysheriff.com/wp-content/uploads/2026/06/ClaimforDamages.pdf

Sparse pages use OCR; original PDF remains authoritative.

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YOLO COUNTY BOARD CLAIM FOR DAMAGES OF SUPERVISORS 625 Court Street, Room 204 TO PERSON OR PROPERTY Woodland, CA 95695 INSTRUCTIONS

1. Claims for death, injury to person or to personal property must be filed not later than six months after the occurrence. (Gov. Code Sec. 911.2.) Claims for damages to real property must be filled not later than 1 year after the occurrence. Read entire claim form before filling. See page 2 for diagram upon which to locate place of accident. This claim form must be signed on page 2 at bottom. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. PAR N RESERVE FOR FILING STAMP CLAIM NO. TO: Date of Birth of Claimant: Name of Claimant: Occupation of Claimant: Home Address of Claimant: City and State: Zip Code: Home Telephone Number: Business Address of Claimant: City and State: Zip Code: Business Telephone Number: Give address and telephone number to which you desire notices or communications to be sent. Claimant's Social Security No: When did DAMAGE or INJURY occur? Names of any county employees involved in INJURY or DAMAGE? Date Time. lf claim is for Equitable Indemnity, give date claimant served with the complaint: Date: Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet. Where appropriate, give street names and address and measurements from landmarks: Describe in detail how the DAMAGE or INJURY occurred: Why do you claim the county is responsible? Describe in detail each INJURY or DAMAGE: _

The amount claimed, as of the date of presentation of this claim, is computed as follows: Damages incurred to date (exact): Estimated prospective damages as far as known: Damage to property... seeeees 8, Future expenses for medical and hospital care....... $ Expenses for medical and hospital care. $ Future loss of earnings Loss of earnings Other prospective special damages.. Special damages for. Prospective general damages...............ccccccscsen$ General damages. wed Total estimate prospective damages...............$ Total damages incurred to date.................. $ Total amount claimed as of date of presentation of this claim: $ Was damage and/or injury investigated by police? If so, what city? Where paramedics or ambulance called? If so, name city or ambulance. If injured, state date, time, name and address of doctor of your first visit WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons known to have information: Name Address Phone Name Address Phone Name Address Phone DOCTORS and HOSPITAL: Hospital Address Date Hospitalized Doctor Address Date-Hospitalized Doctor Address Date Hospitalized READ CAREFULLY For all accident claims, place on following diagram, names of streets, including North, East, South, and West; indicate place of accident by “X” and by showing house numbers or distances to street corners. If County Vehicle was involved, designate by letter “A” location of County Vehicle when you first saw it, and by “B” location of yourself or your vehicle when you first saw County Vehicle; location of County vehicle at time of accident by “A-1” and location of yourself or your vehicle at the time of the accident by “B-1” and the point of impact by “X”. NOTE: If diagram below does not fit the situation, attach hereto a proper diagram signed by claimant. L VL SIDEWALK curRB—} Z PARKWAY SIDEWALK Signature of claimant or person filing on his behalf Printed Name: Date: giving relationship to Claimant: