Claims

2. Charlene Tim, City Clerk

   In compliance with applicable sections of Title 6, Chapter 9, Idaho Code, the undersigned hereby presents a claim against the City of Nampa, Idaho, for damages arising out of an occurrence, which happened as follows:

4. 1. Date and Time of Occurrence*
   1. Date and Time of Occurrence

   1. Date and Time of Occurrence
6. 2. Place or location of Occurrence*
8. 3. Cause of damages*

   (Describe the details or circumstances of the accident or occurrence)

10. 4. Witnesses:
12. Name
13. Address
14. Phone Number
28. 5. Amount of Claim*
    (Attach all bills or other substantiating information verifying the amount of your claim)
30. 6. Bodily injury
    (Describe the extent of your injury, your attending physician, place of emergency treatment and any other pertinent information)
32. 7. Property damage
    (Describe property and vehicle damage)
36. 8. Claimant Information
38. First Name*
39. Last Name*
41. Contact Phone
42. Email Address
44. Address1*
46. Address2
48. City*
49. State*
50. Zip*
52. 9. Additional Parties Involved
    (Please add the name, address and phone number for any additional parties involved)
56. 10. Former Address
    (Required if at current address less than six months)
58. Address1
60. Address2
62. City
63. State
64. Zip
66. 11. Supporting Documentation
    Upload all supporting documentation
68. 12. eSignature
    By checking the box and entering your information below, you hereby declare, under penalties of perjury, that you are authorized to submit the information in this form and to the best of your knowledge, it is true, correct and complete and your authorize it to be processed.
70. 1. Signature
71. First Name*
72. Last Name*
74. Email Address*
75. Date*
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field