City of Nampa Form Center

2. CITY OF NAMPA NOTICE OF CLAIM
4. Charlene Tim, City Clerk

   411 3rd St. S.
   Nampa, ID 83651
   Phone: (208) 468-5415

6. 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:
8. Click the link below if you would prefer to print and complete a paper claim form
   Print and Complete Paper Claim Form
10. 1. Date and Time of Occurrence*
    1. Date and Time of Occurrence

    1. Date and Time of Occurrence
12. 2. Place or location of Occurrence*
14. 3. Cause of damages*
    (Describe the details or circumstances of the accident or occurrence)
16. 4. Witnesses:
18. Name
19. Address
20. Phone Number
34. 5. Amount of Claim*
    (Attach all bills or other substantiating information verifying the amount of your claim)
36. 6. Bodily injury
    (Describe the extent of your injury, your attending physician, place of emergency treatment and any other pertinent information)
38. 7. Property damage
    (Describe property and vehicle damage)
42. 8. Claimant Information
44. First Name*
45. Last Name*
47. Contact Phone
48. Email Address
50. Address1*
52. Address2
54. City*
55. State*
56. Zip*
58. 9. Additional Parties Involved
    (Please add the name, address and phone number for any additional parties involved)
62. 10. Former Address
    (Required if at current address less than six months)
64. Address1
66. Address2
68. City
69. State
70. Zip
74. 11. Supporting Documentation
    Upload all supporting documentation
78. 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.
80. 1. Signature
81. First Name*
82. Last Name*
84. Email Address*
85. Date*
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit Submit and Print

* indicates a required field