City of Nampa Form Center

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  1. 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:

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

  3. 4. Witnesses:
  4. Name
  5. Address
  6. Phone Number
  7. (Attach all bills or other substantiating information verifying the amount of your claim)
  8. (Describe the extent of your injury, your attending physician, place of emergency treatment and any other pertinent information)
  9. (Describe property and vehicle damage)
  10. 8. Claimant Information
  11. (Please add the name, address and phone number for any additional parties involved)
  12. 10. Former Address
    (Required if at current address less than six months)
  13. Upload all supporting documentation
  14. 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.
  15. Leave This Blank:

  16. This field is not part of the form submission.