Free Notice of Claim Against the City of Menasha, Wisconsin

 

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Free Notice of Claim Against the City of Menasha, Wisconsin

Wisconsin law requires a Notice of Claim to be filed within certain statutes of limitations.  You must comply with the time limits in order for your claim to be considered.

NAME  ___________________________________   TELEPHONE

NO._______________

ADDRESS ___________________________________ (street)

  ___________________________________ (city, state, zip code)

CIRCUMSTANCES OF CLAIM: On the reverse side, describe the circumstances of your claim (attach additional sheets if necessary).  For auto/property damages attach a copy of police report, if any; and a diagram of the accident scene including north, south, east or west.  For personal injury indicate the nature of the injury; if medical attention was given, the name of the physician/immediate care/hospital.  List the names and addresses of any witnesses to the incident/accident.  Please be specific with the information provided.

Incident/Accident Information:

Date ________________________  Place:

_______________________________________

Time ________________________   _______________________________________

(Circumstances of claim and witnesses on reverse)

Signed: ______________________________________  Date: ___________________

CLAIM FORM

Wisconsin law requires claims to be filed within certain statutes of limitations.  You must comply with these time limits or any claim submitted will be denied. You are not required to make a claim at this time.  You may file a claim against the City of Menasha at any time consistent with the applicable statute of limitations.   However, in order for the City of Menasha to formally accept or disallow your claim at this time, you must complete and sign the form below.  Please provide copies of any bills supporting the amount of the claim.  Attach two (2) estimates for claims involving auto/truck/property damage. The undersigned hereby makes a claim against the City of Menasha arising out of the circumstances described above.  The claim is for relief in the form of money damages in the amount as indicated below, and non-monetary relief as follows: 

______________________________________________.

 Auto/truck: $_______________   Personal Injury: $_______________

 Property: $_______________   Other (specify:) $_______________

Signed: ______________________________________  Date: ___________________

Address: ______________________________________ (street)

  ______________________________________ (city, state, zip code)