AWC RMSA CLAIM FOR DAMAGES
City or Town City of Gig Harbor Claimant’s Telephone: ( ( Please take notice that
(Print full name)
)
(home)
)
(work)
Who now resides at
(Give residence by street number, PO Box, City, State and Zip Code)
And who, for six months prior to accrual of claim or date of accident, has resided at
Claims damages in the sum of $ occurrence as
(date) (time)
at
, giving date and time of injury or damage , arising out of the following circumstances:
Describe place and full particulars of claim, accurately locating and describing defects causing injury or damage and all acts of negligence claimed: (Use additional pages, if necessary.)
Accurately describe injuries or damages:
State items of damage claimed. Itemize all expenses and losses:
List names and addresses of all witnesses:
(Claimant must swear to claim)
(Signature of claimant)
Subscribed, and sworn to, before me this
(SEAL)
day of
, 20
.
Notary Public in and for the State of Washington,
(Place of residence)
Return to: City of Gig Harbor, 3510 Grandview Street, Gig Harbor, WA 98335