Yuba — GC910 Claim Form

Source: https://www.yuba.courts.ca.gov/system/files/gc9104-claim-form.pdf

FOR COURT OR OFFICIAL USE ONLY FOR COURT OR OFFICIAL USE ONLY

[DATE STAMP]

Postmark date if received by mail: _________GOVERNMENT CLAIM—JUDICIAL BRANCH Postmark date if received by mail: ___________

(Government Code section 910.4)

CLAIMANT

NameNameName ofofof ClaimantClaimantClaimant Home Telephone Work Telephone

Mailing Address City State Zip Code

Send notices regarding this claim to (if different from above): Name

Mailing Address City State Zip Code

CLAIM INFORMATION

DateDate ofof IncidentIncident (Month/Day/Year)(Month/Day/Year) Time of Incident

Location of Incident

Describe the indebtedness, obligation, injury, damage, or loss incurred as a result of the incident.

State the circumstances that gave rise to this claim. (State the facts that support your claim and why you believe the court or another judicial branch entity is responsible for the alleged damage or injury.) If known, provide the name of the official or employee who allegedly caused the injury, damage, or loss (if there is more than one official or employee, name each). If you need more space, please attach additional sheets of paper.

GOVERNMENT CLAIM—JUDICIAL BRANCH

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Name of Claimant: ____________________________

If the total amount of your claim is up to $10,000: If the amount of your claim is more than $10,000, indicate whether your claim would be a limited civil Amount of damages as of this date: case or an unlimited civil case (check one): Estimated amount of future damages: Total amount claimed: Limited civil (amount is $25,000 or less) Unlimited civil (amount is more than $25,000)

State how the amount of your claim was computed (include copies of supporting documentation such as billing statements, invoices, receipts, and estimates).

List the names, addresses, and telephone numbers of all witnesses to the incident.

Provide any additional information that might be helpful in considering this claim.

REPRESENTATIVE (Complete only if claim is presented by someone acting on claimant’s behalf) NameNameName ofofof AuthorizedAuthorizedAuthorized RepresentativeRepresentativeRepresentative Telephone

MailingMailingMailing AddressAddressAddress City State Zip Code

PLEASE NOTE: Presentation of a false claim with intent to defraud is a criminal offense (Penal Code section 72).

Signature of □ Claimant or □ Authorized Representative (check one) Date

Deliver or mail this claim form to:

Attention: Court Executive Officer (Claims) Superior Court of California, County of Yuba 215 5TH ST STE 200 Marysville, CA 95901

GOVERNMENT CLAIM—JUDICIAL BRANCH

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