SSAMPLE DISTRICT TORT
CLAIM FORM
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Bickleton School District]
TORT CLAIM FORM
RCW 4.96.020
Pursuant to Chapter 4.96 RCW, this form is for
filing a tort claim against the Bickleton School District. Information
requested on this form is required by RCW 4.96.020 and may be subject
to public disclosure. Any person wishing to file a tort claim with the
District should fill this form out accurately and completely and present
the form in person or by mail to the Superintendent of the Bickleton School
District at the address given below between the weekday business hours
of 7:45 am and 4:30 pm.
Present to the Superintendent at:
100 E. Market St.,
Bickleton, WA 99322
For School District Use Only:
Date Received:
CLAIMANT INFORMATION
1. Claimant's Name: _________________________________________________________________________
2. Claimant’s Date of Birth: ___________________________________________________________________
3. Claimant’s Current Residential Address:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4. Claimant’s Mailing Address (if different):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
5. Claimant’s Residential Address at the Time of
the Incident (if different from current address):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6. Claimant’s Daytime Phone Number: _____________________________________________________
7. Claimant’s E-Mail Address: __________________________________________________________
INCIDENT INFORMATION
8. State the amount of damages claimed against
the District as a result of the incident.
$__________________
9. Date of the incident: _________________________
Time: _______________________________________ a.m./p.m. (circle one)
10. Location of incident: ___________________________________________________________
11. Names, addresses and telephone numbers of all
persons involved in this incident or who were witnesses to this incident:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(List additional names of witnesses and their contact
information, if any, on a separate page and attach to this page.)
12. Names, addresses and telephone numbers of all
District employees having knowledge about this incident:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(List additional names of District employees and
their contact information, if any, on a separate page and attach to this
page.)
13. Describe the injury or damage which resulted
from the incident.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(List additional information, if any, on a separate page and attach to
this page.)
14. What is the basis for making this claim against
the District? Please provide specific details regarding the conduct and
circumstances that you believe the District or its employees engaged in
that caused your injury or damage. (Such information can also be provided
on separate pages attached to this page.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Attorney
15. Attorney’s contact information if you are represented in this matter
by an attorney:
Name: ______________________________________________________________________
Phone: _____________________________________________________________________
Email: ______________________________________________________________________
Address: ____________________________________________________________________
____________________________________________________________________________
Signature and Verification
16. This Claim form must be signed by the Claimant,
a person holding a written power of attorney from the Claimant, by the
attorney in fact for the Claimant, by an attorney admitted to practice
in Washington State on the Claimant's behalf, or by a court-approved guardian
or guardian ad litem on behalf of the Claimant.
I declare under penalty of perjury of the laws
of the State of Washington that the foregoing information is true and
correct.
DATED: __________________________, ___________
at ________________, Washington.
_______________________________________________
Signature (actual, non-electronic signature required)
_______________________________________________
Print the Name of the Person Signing
Bickleton School District]
TORT CLAIM FORM
RCW 4.96.020
Pursuant to Chapter 4.96 RCW, this form is for filing a tort claim against the Bickleton School District. Information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. Any person wishing to file a tort claim with the District should fill this form out accurately and completely and present the form in person or by mail to the Superintendent of the Bickleton School District at the address given below between the weekday business hours of 7:45 am and 4:30 pm.
Present to the Superintendent at:
100 E. Market St.,
Bickleton, WA 99322
For School District Use Only:
Date Received:
CLAIMANT INFORMATION
1. Claimant's Name: _________________________________________________________________________
2. Claimant’s Date of Birth: ___________________________________________________________________
3. Claimant’s Current Residential Address:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4. Claimant’s Mailing Address (if different):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
5. Claimant’s Residential Address at the Time of the Incident (if different from current address):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6. Claimant’s Daytime Phone Number: _____________________________________________________
7. Claimant’s E-Mail Address: __________________________________________________________
INCIDENT INFORMATION
8. State the amount of damages claimed against the District as a result of the incident.
$__________________
9. Date of the incident: _________________________
Time: _______________________________________ a.m./p.m. (circle one)
10. Location of incident: ___________________________________________________________
11. Names, addresses and telephone numbers of all
persons involved in this incident or who were witnesses to this incident:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(List additional names of witnesses and their contact information, if any, on a separate page and attach to this page.)
12. Names, addresses and telephone numbers of all
District employees having knowledge about this incident:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(List additional names of District employees and their contact information, if any, on a separate page and attach to this page.)
13. Describe the injury or damage which resulted
from the incident.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(List additional information, if any, on a separate page and attach to
this page.)
14. What is the basis for making this claim against the District? Please provide specific details regarding the conduct and circumstances that you believe the District or its employees engaged in that caused your injury or damage. (Such information can also be provided on separate pages attached to this page.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Attorney
15. Attorney’s contact information if you are represented in this matter
by an attorney:
Name: ______________________________________________________________________
Phone: _____________________________________________________________________
Email: ______________________________________________________________________
Address: ____________________________________________________________________
____________________________________________________________________________
Signature and Verification
16. This Claim form must be signed by the Claimant, a person holding a written power of attorney from the Claimant, by the attorney in fact for the Claimant, by an attorney admitted to practice in Washington State on the Claimant's behalf, or by a court-approved guardian or guardian ad litem on behalf of the Claimant.
I declare under penalty of perjury of the laws of the State of Washington that the foregoing information is true and correct.
DATED: __________________________, ___________ at ________________, Washington.
_______________________________________________
Signature (actual, non-electronic signature required)
_______________________________________________
Print the Name of the Person Signing
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