Potential Liability Incident Report
Potential Liability Incident Report Form. This is a Nevada form and can be use in Office Of Attorney General Statewide.
Tags: Potential Liability Incident Report, TC-2, Nevada Statewide, Office Of Attorney General
COURT COUNTY OF ...................................................... : : State of Nevada: AG Office use ONLY: Index No. Date TC-1 sent ________ Calendar No. JUDICIAL SUBPOENA Plaintiff(s) Potential Liability Incident Report -against: INSTRUCTIONS: : Agency should use this form to report potential liability claims against the State. : ASAP to: Original of this “Incident Report” should be sent Defendant(s) Claims Manager, Office of the Attorney General, : . . . . . . . . 100 . . . . .North . . . . . .Carson . . . . . . . .Street, . . . . . . . Carson . . . . . . . . City . . . . . NV . . . . 89701-4717 ... If an individual wishes to make a formal claim against the State, the individual should notify the Office of the Attorney General at TEL: 775/684-1263; FAX. 775/684-1275. The Attorney THE PEOPLE OF THE STATE OF NEW YORK General’s Office will send the appropriate form to the injured/damaged party. TO PLEASE NOTE: Do not use this form to report injuries of State employees; a Worker’s Compensation injury report must be filed in those instances. Please type or print clearly GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Name of Inured/Damaged Party: , at the Court located at in room , on the day of , at o'clock in the Telephone No. Date of, 20 Incident: Time:noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the the Honorable MailingCounty Address: of Location where incident occurred (include street address): Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Department: Division: Budget the party on whose behalf this subpoena was issued for a maximum penalty of $50 Account: and all damages sustained as a result of your failure to comply. Contact Person: Title: Telephone No.: Please provideWitness, a detailed description of what happened & attach all supporting documentation you Honorable , one of the Justices of the may have. (Attach additional pages if necessary): Court in County, day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Form completed by: TC-2 (revision of RSK-002, 6/04) Office of the Attorney General Telephone No.: Facsimile No.: Date: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com