Claim for Damage

Ada County

NOTICE OF CLAIM BY CITIZEN TO ADA COUNTY

Your claim must be filed and received by Ada County no later than 180 days from the date of the incident.
PERSONAL INFORMATION
Name of Claimant:*
Address:*
Street Address Address Line 2 City State ZIP Code
Phone:
Email:*
CLAIM INFORMATION
In compliance with Title 6, Chapter 9, Idaho Code, the undersigned hereby presents a claim against Ada County for damages arising out of an occurrence which happened as follows:
Date:*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Location:
Cause of Damage (Describe the details and circumstances of the accident or occurrence):
Person(s) Involved and/or Witnesses of Damage and/or Injury:
1. Name:
1. Phone:
1. Address:
Street Address Address Line 2 City State ZIP Code
2. Name:
2. Phone:
2. Address:
Street Address Address Line 2 City State ZIP Code
3. Name:
3. Phone:
3. Address:
Street Address Address Line 2 City State ZIP Code
PROPERTY DAMAGE (IF APPLICABLE)
Describe Property (Please provide as much detail as possible):
Describe Property Damage:
Property Damage Amount: $
PERSONAL INJURY (IF APPLICABLE)
Describe Personal Injuries:
Date:*
MM slash DD slash YYYY
Signature:*
Ada County 200 W. Front St. Boise, Idaho 83702
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PERSONAL INFORMATION