Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 Property Damage Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS Claimant vs. Respondent, STATE OF ILLINOIS ) ) ) ) ) ) ) ) COURT USE ONLY Claim #: _______________________ Amount: _______________________ Claimant seeks from Respondent payment in the sum of $ ____________________ for property damage received as stated on the attached statement/narrative of events (with attached copies of bills, receipts, etc.), and made a part hereof as Exhibit “A.” This property damage has resulted from the actions of the ________________________________________ Department, Board, Commission of the State of Illinois. This is a claim in tort under the provisions of Section 8(d) of the Illinois Court of Claims Act (705 ILCS 505 etc seq.). 1. 2. In support thereof, the Claimant states property damage as follows (attach additional pages if necessary): ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ❑ The Claimant has not previously presented this claim to any State department or officer thereof; or ❑ The Claimant did present bills in connection with this claim to _____________________________________ Department, Board, Commission 3. 4. 5. 6. on the _______________ day of ________________ , 20 ___ , and was referred to the Court of Claims for appropriate resolution. The Claimant is the proper owner of this claim. No assignment or transfer of this claim, or any part thereof or interest therein, has been made. The Claimant is entitled to payment in the amount herein claimed from the State of Illinois after allowing just credits. The Claimant believes all the facts stated in this claim to be true. Printed by authority of the State of Illinois - March 2005 - 500 - CC-85 American LegalNet, Inc. www.USCourtForms.com 7. 8. ❑ Neither this claim, nor any claim arising out of the same occurrence, has been presented to any person, corporation or tribunal other than the State of Illinois; or ❑ This claim was presented to _____________________ , a person, corporation or tribunal not affiliated with the State of Illinois, on the _______________ day of ________________ , 20 ___, with the following result: (Indicate payments, denials, etc. and attach copies of all documents.) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ The Claimant further states that his/her Social Security Number is: ______________________________________ _______________________________________________ Claimant Signature ________________________________________________ ________________________________________________ Claimant Claimant’s Attorney ________________________________________________ ________________________________________________ City ________________________________________________ OR Street Address Street Address ________________________________________________ State City ________________________________________________ ZIP State ________________________________________________ Telephone Number ZIP Telephone Number Subscribed and sworn to me this ____________________ day of _________________________ 20 _____. ______________________________________________ Notary Public Procedures for Filing Property Damage Claims Against the State of Illinois 1. Complete the attached Court of Claims complaint form in its entirety, including your Social Security Number or your Federal Employee Identification Number (F.E.I.N.). 2. If you are represented by an attorney, complete the appropriate section of the complaint form so that all correspondence may be directed to the attorney’s office. An attorney is not required in order to file a Property Damage Claim. 3. Sign both claimant lines of the complaint form. Please print your name in the space in between signatures. 4. A filing fee is required to file a Property Damage Claim ($15 for claims under $1,000; $35 for claims over $1,000). The filing fee must be included when the claim is submitted. 5. Collate the original complaint form, along with any itemized bills, invoices, denial letters or other materials that substantiate your claim. Make five additional copies of the complaint form and attach the supporting documentation to each one of the complaint forms (original plus five copies of each document) and mail to: Illinois Court of Claims 630 S. College St. Springfield, IL 62756 Printed by authority of the State of Illinois - March 2005 - 500 - CC-85 American LegalNet, Inc. www.USCourtForms.com