FOR COURT OR OFFICIAL USE ONLY GOVERNMENT CLAIM-JUDICIAL BRANCH (Government Code section 910.4) Postmark date if received by mail: CLAIMANT Name of Claimant 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 Date of Incident (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. ADM 116 N 08/18PAGE 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com GOVERNMENT CLAIM-JUDICIAL BRANCH 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 damage as of this date: Estimated amount of future damages: Total amount claimed: case or an unlimited civil case (check one): 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) Name of Authorized Representative Telephone Mailing Address 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: Office of Court Counsel Superior Court of California, County of Los Angeles Stanley Mosk Courthouse 111 North Hill Street, Room 546 Los Angeles, CA 90012 PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com