STATE APPEAL BOARD CLAIM FORM AND AFFIDAVIT This form is also available on the Internet at CLAIM NUMBER (for Appeal Board use only) Submit to: http://www.dom.state.ia.us/appeals/index.html STATE APPEAL BOARD Department of Management State Capitol, 1007 E. Grand Ave, Room 13 Des Moines, Iowa 50319 DATE RECEIVED: (for Appeal Board use only) Directions: A TORT CLAIM MUST submit 3 complete sets of documents, an original form with any attachments and two claim form copies with attachments for EACH, CLAIMANT and NOTARY PUBLIC must sign. A GENERAL CLAIM MUST submit 2 complete sets of documents, an original and one copy, with attachments for EACH . Please see specific directions on the back of this form that pertain to the type of claim you are filing. 1. NAME OF CLAIMANT (please print full name) 2. DATE OF BIRTH 3. ADDRESS OF CLAIMANT (Street, City, State, Zip Code) Email Address 5. CLAIMANT'S SOCIAL SECURITY NUMBER 6. IDENTIFY STATE AGENCY OR DEPARTMENT INVOLVED 7. LOCATION OF ACCIDENT/INCIDENT 4. TELEPHONE: HOME BUSINESS ( ( ) ) OR FEDERAL TAX IDENTIFICATION NUMBER 8. DATE/TIME OF ACCIDENT/INCIDENT 9. SELECT TYPE OF CLAIM: place an X in the box (A SEPARATE claim must be filed by each claimant for each of the three types of claims defined below) (1) GENERAL _________________ AMOUNT OF CLAIM FOR TORT CLAIMS, INDICATE ONE OF THE FOLLOWING: (2) TORT CLAIM AGAINST THE STATE (3) TORT CLAIM AGAINST STATE EMPLOYEE(S) Give employee(s) name and department PROPERTY DAMAGES $ PERSONAL INJURY $ WRONGFUL DEATH $ 10. BASIS OF CLAIM (Please provide all the information required on the reverse side of this form. Attach separate sheets if necessary.) 11. NAME, ADDRESS, TELEPHONE # AND EMAIL ADDRESS OF ATTORNEY, IF ONE HAS BEEN RETAINED IN THIS CASE. 12. ATTORNEY'S SOCIAL SECURITY NUMBER OR FEDERAL TAX IDENTIFICATION NUMBER I, the claimant, being duly sworn upon oath depose and state that I have read the supplied information and the same is true and correct to the best of my belief. CLAIMANT'S SIGNATURE Subscribed and sworn to before me this day of , 20______ My commission expires NOTARY PUBLIC SIGNATURE American LegalNet, Inc. www.FormsWorkFlow.com TYPE 1: GENERAL CLAIMS TYPE 1: GENERAL CLAIMS (25.2) The State Appeal Board, with the recommendation of the Special Assistant Attorney General for claims, may approve or reject claims against the state of less than five years covering the following: outdated warrants; outdated sales and use tax refunds; license refunds; additional agricultural land tax credits; outdated invoices; fuel and gas tax refunds; outdated homestead and veteran's exemptions; outdated funeral service claims; tractor fees; registration permits; outdated bills for merchandise; services furnished to the state; claims by any county or county official relating to the personal property tax credit; and refunds of fees collected by the state. INSTRUCTIONS TO CLAIMANT Statements, information, and evidence concerning the following items are required to support your claim. 1. Itemized statement for services rendered or merchandise furnished and the name of the state agency or employee involved. Explain why the invoice was not submitted within the current fiscal year. 2. If for a refund, explain in detail and indicate state agency involved. 3. Complete information concerning claim must be given together with amount claimed in dollars. 4. State employees claiming expenses must attach standard expense form with the agency certification signature, and explain why expenses were not submitted within the current fiscal year. If your General Claim is denied by the State Appeal Board, it will automatically be presented to the General Assembly. TYPE 2 & 3: TORT CLAIMS TYPE 2 & 3: TORT CLAIMS (669.2(3)) a. Any claim against the State of Iowa for money only, on account of damage to or loss of property, or on account of personal injury or death caused by the negligent or wrongful act or omission of any employee of the state while acting within the scope of the employee's office or employment under circumstances where the state, if a private person, would be liable to the claimant for such damage, loss, injury, or death. b. Any claim against an employee of the state for money only, on account of damage to or loss of property, or on account of personal injury or death caused by the negligent or wrongful act or omission of any employee of the state while acting within the scope of the employee's office or employment. NOTICE TO CLAIMANT I. Describe accident, and state in detail all known facts and circumstances attending the damage or injury, the state agency and property involved, and the cause thereof, and the names and addresses of all persons who have knowledge of any relevant facts relating to the claim. II. If an insurance carrier has subrogation rights, provide name, address, and policy number. III. In support of claim for personal injury or death, claimant shall submit the following information: A. Detailed description of nature, extent, and duration of any and all injuries. B. If treated by doctors, the name and address of each doctor, the dates and places where treatments were received, and the date of the last treatment. C. If any hospital confinement, the name and address of each doctor, the dates and places where treatments were received, and the date of the last treatment. D. If a previous injury, disease, illness, or condition is claimed to have been aggravated or accelerated, specify in detail the nature of each, and the name and present address of each doctor, if any, who rendered or is rendering treatment for said condition. E. If employed at the time of accident, state: (1) The name and address of the employer; (2) Position held and nature of work performed; (3) Average weekly wage for past year; (4) Period of time lost from employment, giving dates; and (5) Amount of wages lost, if any. F. If other loss of income, profit, or earnings is claimed, state: (1) The total amount of said loss in complete computation; (2) Nature and source of loss of such income, profit, or earnings; (3) Date of deprivation thereof; (4) Period of time of such loss; and (5) Whether loss is still continuing. G. If there has been a return to employment or occupation, state: (1) Name and address of present employer; (2) Position held and nature of work performed; and (3) Present weekly wages, earnings, income, or profit. H. Itemize in complete detail all monies expended or expenses incurred, in a