FOR COURT OR OFFICIAL USE ONLY FOR COURT OR OFFICIAL USE ONLY [DATE STAMP] GOVERNMENT CLAIM--JUDICIAL BRANCH (Government Code section 910.4) Postmark date if received byby mail: _________ Postmark date if received mail: ___________ CLAIMANT Name of Claimant Mailing Address City Home Telephone State Work Telephone 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) Location of Incident Describe the indebtedness, obligation, injury, damage, or loss incurred as a result of the incident. Time of 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 PAGE 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Name of Claimant: ____________________________ If the total amount of your claim is up to $10,000: Amount of damages as of this date: Estimated amount of future damages: Total amount claimed: If the amount of your claim is more than $10,000, indicate whether your claim would be a limited civil 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 Mailing Address City Telephone 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 PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com