Los Olivos SD | E 3320 Business and Noninstructional Operations
Claim Form Against Los Olivos School District
Government Code Sections 910 and 910.2
Name of Claimant:_______________________________________________
Address:_________________________________________________________________________________
Phone Number:_______(day)_________ ______(evening)_________
Date the injury/damage occurred:_________________________
Place the injury/damage occurred:___________________________________
Describe how and under what circumstances the injury/damage occurred:_______________________________
__________________________________________________________________________________________
What particular action by the district and/or its employees caused the alleged damage or injury: (List employee name(s), if known):__________________________________________________________________________
__________________________________________________________________________________________
State the amount of the claim if it is less than $10,000? $_____________
Include the estimated amount of any prospective injury, damage or loss insofar as it may be known at the time this claim is presented and list the basis for the computation of the amount claimed: ____________________________________________________________________________________________________________________________________________________________________________________
If the dollar amount is more than $10,000, no dollar amount shall be stated but please indicate whether the claim is a limited civil claim (total dollar amount less than $25,000):
Limited Civil Case: Yes______ No_________
Names, addresses and phone numbers of any witnesses, doctors, and hospitals:__________________________ __________________________________________________________________________________________
Warning: It is unlawful to knowingly present or cause to be presented any false or fraudulent claim for payment of a loss or injury. Penal Code Section 500 provides that a person who files such a claim may be guilty of a felony punishable by imprisonment and by a fine not exceeding $50,000
Signature:________________________________ Date:____________________________
Exhibit LOS OLIVOS SCHOOL DISTRICT
version: February 9, 2004 Los Olivos, California
________________________________________________________________________
E(2) 3320
CLAIMS AND ACTIONS AGAINST THE DISTRICT
NOTICE OF FAILURE TO USE DISTRICT'S CLAIM FORM
Government Code Section 910.4
TO: [Claimant]
[Address]
RE: Claim Filed [date]
The claim you presented to the Superintendent/Principal or designee on [date] is being returned because it was not presented on the district's claim form as required by Government Code Section 910.4 and in accordance with Board policy and administrative regulation. Because the claim was not presented on the district's form, no action was taken on the claim.
You may resubmit your claim using the district's claim form, which may be obtained at the district office. Note that your claim must still comply with the time limits in the Government Code specified for filing of such claims. For further information, call [phone number].
Exhibit LOS OLIVOS SCHOOL DISTRICT
version: February 9, 2004 Los Olivos, California
________________________________________________________________________
E(3) 3320
CLAIMS AND ACTIONS AGAINST THE DISTRICT
NOTICE OF INSUFFICIENCY
Government Code Section 910.8
TO: [Claimant]
[Address]
RE: Claim Filed [date]
The claim presented by you on [date] fails to comply substantially with the requirements of Government Code Sections 910 and 910.2 or with the requirements of the district's claim form provided under Government Code Section 910.4. Specifically, your claim is insufficient because of the following defects or omissions:
Therefore, the claim is being returned to you without further action or consideration. If you wish to pursue this further, you should consult the Government Code or legal counsel.
The Board of Trustees will not take any action on the claim for a period of fifteen (15) days from the date of this notice.
Dated:
Signature
Typed Title of Officer
Exhibit LOS OLIVOS SCHOOL DISTRICT
version: February 9, 2004 Los Olivos, California
_________________________________________________________________________
E(4) 3320
CLAIMS AND ACTIONS AGAINST THE DISTRICT
NOTICE OF FAILURE TO FILE IN A TIMELY MANNER
Government Code Section 911.3
TO: [Claimant]
[Address]
RE: Claim Filed [date]
The claim you presented to the Superintendent/Principal or designee on [date] is being returned because it was not presented within six months after the event or occurrence as required by law. See Sections 901 and 911.2 of the Government Code. Because the claim was not presented within the time allowed by law, no action was taken on the claim.
Your only recourse at this time is to apply without delay to [district name] for leave to present a late claim. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present a late claim will be granted. See Section 911.6 of the Government Code.
You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately.
Exhibit LOS OLIVOS SCHOOL DISTRICT
version: February 9, 2004 Los Olivos, California
_______________________________________________________________________
E(5) 3320
CLAIMS AND ACTIONS AGAINST THE DISTRICT
DENIAL OF APPLICATION TO FILE A LATE CLAIM
Government Code Section 911.8
TO: [Claimant]
[Address]
RE: Claim Filed [date]
Your application to file a late claim presented on [date] has been denied. The Board of Trustees has determined that your claim does not satisfy one of the four conditions listed in Government Code Section 911.6.
WARNING
If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 945.6. Such petition must be filed with the court within six (6) months from the date your application for leave to present a late claim was denied.
You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately.
Exhibit LOS OLIVOS SCHOOL DISTRICT
version: February 9, 2004 Los Olivos, California
_________________________________________________________________________
E(6) 3320
CLAIMS AND ACTIONS AGAINST THE DISTRICT
NOTICE OF ACTION TAKEN ON CLAIM
Government Code Section 913
Dear :
Notice is hereby given that the claim you presented to the [district name] on [date] was [rejected, allowed, allowed in the amount of $ and rejected to the balance, rejected by operation of law or other appropriate language, whichever is applicable] on [date of action or rejection by operation of law].
WARNING
Subject to certain exceptions, you have only six (6) months from the date this letter was personally delivered or deposited in the mail to file a court action on this claim. See Government Code Section 945.6.
You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately.
Dated:
Signature
Typed Title of Officer
Exhibit LOS OLIVOS SCHOOL DISTRICT
version: February 9, 2004 Los Olivos, California