CLAIMS FOR DAMAGES TIME STAMP
OFFICE USE ONLY
COUNTY OF LOS ANGELES TO PERSON OR PROPERTY
INSTRUCTIONS:
1. Read claim thoroughly.
2. Fill out claim as indicated; attach additional information if necessary.
3. Please use one claim form for each claimant.
4. Return this original signed claim and any attachments
supporting your claim. This form must be signed.
DELIVER OR U.S. MAIL TO:
EXECUTIVE OFFICER, BOARD OF SUPERVISORS, ATTENTION: CLAIMS
500 WEST TEMPLE STREET, ROOM 383,
KENNETH HAHN HALL OF ADMINISTRATION, LOS ANGELES, CA 90012
(213) 974-1440
1. Mr. □ Ms. □ Mrs. LAST NAME FIRST NAME M.I. 10. WHY DO YOU CLAIM COUNTY IS RESPONSIBLE?
Anderson James Robert The county may be responsible if the tree was on county property or if
they failed to maintain or remove a dangerous tree. If the tree was dead,
2. ADDRESS OF CLAIMANT
weak, or a known hazard and the county did nothing, they could be liable
Apt 5B, 13th Street,Los Angeles, CA 90012 for the damage.
CITY STATE ZIP CODE
Los Angeles CA 90012
HOME PHONE ALTERNATE PHONE
(310) 555-5678 (310) 555-5679
3. CLAIMAINT’S BIRTHDATE: 4. CLAIMANT’S SOCIAL SECURITY NUMBER
02/13/2025 545-78-0511
5. ADDRESS TO WHICH CORRESPONDENCE SHOULD BE SENT
American Family Insurance
STREET CITY STATE ZIP CODE
Los Angeles CA 90015
6. DATE AND TIME OF INCIDENT 11. NAMES OF ANY COUNTY EMPLOYEES (AND THEIR DEPARTMENTS)
INVOLVED IN INJURY OR DAMAGE (IF APPLICABLE):
8/4/2024 3:26 pm
7. WHERE DID DAMAGE OR INJURY OCCUR? NAME DEPARTMENT
House roof damaged Sarah Adams County Administrator
STREET CITY STATE ZIP CODE NAME DEPARTMENT
Los Angeles CA 90012 James Walker Health Department Official
8. DESCRIBE IN DETAIL HOW DAMAGE OR INJURY OCCURRED AND LIST DAMAGES 12. WITNESS(ES) TO DAMAGES OR INJURY: LIST ALL PERSONS AND
(attach copies of receipts or repair estimates): ADDRESSES OF PERSONS KNOWN TO HAVE INFORMATION:
A tree fell on the roof of the house, causing damage. The impact
damaged the roofing materials, and there may be structural issues. NAME PHONE
Michael Thomas Johnson (310) 424-5261
ADDRESS
Apt 5B, 13th Street,Los Angeles, CA 90012
NAME PHONE
NA
ADDRESS
NA
9. WERE POLICE OR PARAMEDICS CALLED? YES NO 13. IF PHYSICIAN(S) WERE VISTED DUE TO INJURY, PROVIDE NAME, ADDRESS,
PHONE NUMBER, AND DATE OF FIRST VISIT FOR EACH:
NA
(IF YES) AGENCY’S NAME _____________________________ NA
REPORT # ________________ DATE OF FIRST VISIT PHYSICIAN’S NAME PHONE
08/04/2024 Matthew Joseph Davis (310) 785-1973
STREET CITY STATE ZIP CODE
CHECK IF LIMITED CIVIL CASE
Apt 5B, 13th Street Los Angeles CA 90012
DATE OF FIRST VISIT PHYSICIAN’S NAME PHONE
TOTAL DAMAGES TO DATE TOTAL ESTIMATED PROSPECTIVE DAMAGES
09/04/2024 Joshua Henry Wilson (310) 731-9435
STREET CITY STATE ZIP CODE
5,000.00
$__________________________ 15,000.00
$_______________________________
Apt 5B, 13th Street Los Angeles CA 90012
THIS CLAIM MUST BE SIGNED
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (PENAL CODE SECTION 72)
CLAIMS FOR DEATH, INJURY TO PERSON OR TO PERSONAL PROPERTY MUST BE FILED NOT LATER THAN 6 MONTHS AFTER THE OCCURRENCE.
(GOVERNMENT CODE SECTION 911.2)
ALL OTHER CLAIMS FOR DAMAGES MUST BE FILED NOT LATER THAN ONE YEAR AFTER THE OCCURRENCE. (GOVERNMENT CODE SECTION 911.2)
14. PRINT OR TYPE NAME 15. SIGNATURE OF CLAIMANT OR PERSON FILING ON HIS/HER DATE
DATE BEHALF GIVING RELATIONSHIP TO CLAIMANT
James Robert Anderson 06/15/2024 06/15/2024
Revised 11-2016
