Please read these instructions carefully: Answer all items fully and to the best of your knowledge and information. Failure to do so may result in your claim being found insufficient. If more space is needed to provide requested information, attach additional pages and identify the item number. Claims related to injury to person or damage to personal property must be presented to the City within six (6) months from the date of loss. Claims related to any other loss must be presented no later than one (1) year from the date of loss. Return your completed form to: City Clerk, City of Port Hueneme, 250 N. Ventura Road, Port Hueneme, CA 93041.
Please attach receipts, estimates, photos or any type of documentation in support of your claim.
All notices and communications with regard to this claim will be directed to the Claimant previously named above unless you complete the following to identify to whom further communication should be directed:
I/We, the undersigned, declare under penalty of perjury that I/we have read the foregoing claim for damages and know the contents thereof; that the same is true of my/our own knowledge and belief, save and except as to those matters wherein stated on information and belief, and as to them, I/we believe to be true. By entering our name, we are agreeing this is a signature on this document
Penal Code Section 72 makes it a crime punishable by imprisonment to submit a “false or fraudulent claim” for payment to a city or public district, and Code of Civil Procedures Section 1038 authorizes the award of attorney fees against a claimant who brings a claim that is “not brought in good faith and with reasonable cause.”
This field is not part of the form submission.
* indicates a required field