Date notice was received: (this section is to be completed by municipality, county or district.)



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DATE NOTICE WAS RECEIVED: ______________________

(THIS SECTION IS TO BE COMPLETED BY MUNICIPALITY, COUNTY OR DISTRICT.)
Revised 1/2015)
NOTICE OF CLAIM
The following claim is submitted as an itemized written claim in accordance with the Wyoming Governmental Claims Act (W.S. 1-39-113(a), (b)). NOTE: This claim form is to be completed by the claimant and submitted to the governmental entity shown below:

GOVERNMENTAL ENTITY NAME AND ADDRESS that you are filing a claim against; i.e., city, town, county, special district, etc. (DO NOT ENTER, “PUBLIC WORKS” OR AN EMPLOYEE NAME): ___________________________________________________________________________

Address____________________________________________________________________


CLAIMANT INFORMATION: (MUST BE OWNER OF DAMAGED PROPERTY) NOTE: If a minor is involved (under 18), the parent or guardian must complete and sign the claim form and state they are doing so on behalf of the minor.
Full Name:_________________________________________________________________

Mailing Address:___________________________________________________________

___________________________________________________________________________



City_________________________________State________________Zip______________

Physical Address (if different from mailing address):

___________________________________________________________________________


City_________________________________State________________Zip______________

Cell:_____________________Other Daytime Phone:_____________________________

FAX:______________________Email (Optional):__________________________________

NOTE: YOUR EMAIL ADDRESS WILL NOT BE EXPOSED AS ALL CLAIM FILES ARE CONFIDENTIAL; BUT SUPPLYING IT MAY POSSIBLY EXPEDITE YOUR CLAIM PAYMENT.


Did this matter involve a business? Was the property of your business damaged? If so, please enter business name and address: ___________________________________________________________________________

___________________________________________________________________________


Date and time of loss (if unknown, please state date of discovery):
Date:________________________________________Time _____________AM PM (Circle one)

(Month, Day, Year) Please note that noon is 12:00 P.M.



Specific location of loss or injury (Where did it occur? Address?): ___________________________________________________________________________

City_______________________________________State___________________________

PLEASE DESCRIBE IN DETAIL THE CIRCUMSTANCES OF THE LOSS AND/OR INJURY. Submit photos, statements from witnesses, estimates for repair, receipts, or any other information that would help to support your claim. (PLEASE PRINT CLEARLY. DO NOT ENTER “SEE ATTACHED RECEIPTS”. YOUR SIDE OF THE STORY IS NECESSARY.)

___________________________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________ Please attach an additional sheet to this claim form if additional space is needed. If there are multiple claimants arising out of one occurrence, each claimant needs to complete a “Notice of Claim” form.


Amount of damages demanded: $ ____________________ (Provide documentation to support your demand. DO NOT LEAVE BLANK – provide estimate.)
Name of employee/dept. involved, if known: _________________________________
Name of claimant’s attorney, if any: _______________________________________
This “Notice of Claim” form is provided only for the information and convenience of the claimant, who is responsible for completing the form properly and accurately in accordance with the statutory requirements and for presenting it to the proper entity. The governmental entity, which provided this form, makes no representations as to the sufficiency of the form or accuracy of the information provided.

The governmental entity expressly reserves the right to deny the claim on any basis, including the insufficiency or timeliness of the claim and that the claimant should consult with legal counsel if they have any questions.

It is the claimant’s responsibility to fully comply with all the requirements of the Wyoming Governmental Claims Act (W.S. 1-39-101 through 1-39-120), including the applicable statutory time limits for the filing of your claim and commencement of a suit. Your failure to follow the requirements of the Wyoming Governmental Claims Act may result in your claim being forever barred.

I (We)_____________________________________, have read and understand the provisions of the false swearing statute. I hereby certify under penalty of false swearing that the foregoing claim, including all of its attachments, if any, is true and accurate and that the claim is in compliance with the signature and certification requirements of Article 16, Section 7 of the Wyoming Constitution.

________________________________________________ ____________________

Signature of Claimant Date


_______________________________________________

Printed Name of Claimant
State of _________________________________________)

County of ________________________________________)

Subscribed and sworn to before me, a Notarial Officer (Notary), this

_____________________________ day of ___________________, __________

Notarial Officer (Notary) ____________________________________

My Commission Expires: ______________________________



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