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  • Tort Claims F 95 Template

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    Tort Claims f 95 Template

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    Tort Claims f 95 Template

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    Tort Claims f 95 Template

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    46 views1 page

    Tort Claims F 95 Template

    Uploaded by

    landmarkchurchofhouston
    Tort Claims f 95 Template

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 1
    CLAIM FOR DAMAGE INSTRUCTIONS: Peso red cavuly he nstucions on tho] FORM APPROVED * reverse side and supply information requested on both sides of this | OMB NO. 1105-0008 INJURY, OR DEATH {erm Use dstinal sect) nocesery, See verse ter ection nstuctons [Submit propa Federal Agony 7. Name, adios of Gainer nd daiants persona presente Tany {See insroctone on revere) Nuer, See ly, Sate and Zo cose. FEDERAL AGENCY NAME First Middle Last 1234 THEIR ADDRESS ST. c/o 1234 Your Address Street CITY / TOWN, ST 12345 City / Town, State [12345] TYPE OF EMPLOYMENT Tz DATE GFBRTH |S UARTAL STATUS DATE AND DAY OF ACODENT TIMED ORF) Causey low [BIRTH DATE) meerepZDOWED| Monday, xx / xx / year| 12:00 P.M. 5. BASIS OF GLAM (Slaten etal he krown oc and Grcunsances lending the daaGe Wry. o Get denng persone and prope ake eae of ecauence and the caune eroat Use adstona pages necassay) STTAIS’ IS NOT A TEMPLATE, DO YOUR DUE DILIGENCE.** claimant was deprived of his/her natural rights by way of fraud and unlawfully Jdetained without his/her consent on the date of Month xx, Year around the time lof 12:00 P.M. until the date of Month xx, Year. Claimant was denied due process lof 1aw and applicable rights and remedies. See attached statement of facts and Affidavit of Truth. fe PROPERTY DAMAGE INANE AND ADDRESS OF OWNER. IF OTHER THAN CLANANT [Namber, Steet, Gy, Sate and Zip Code) LEAVE BLANK** (Se neructone on revere ss), ** Provide if property was damaged. ** ro PERSONAL INJURVIWRONGFUL DEATH [OF THE INJURED PERSON OR DECEDENT. Claimant suffered unlawful arrest and detention resulting in damages including lout not limited to loss of income and total deprivation of civil rights. see attached statement of facts and Affidavit of Truth. NAME [ADDRESS (Number Steet. iy, Sat, and Zip Code) 1234 Witness Address Street City / Town, State [12345] 1234 Witness Address Street City / Town, State [12345] Witness Name One Witness Name Two 2 (See instucons on reverse) [AMOUNT OF CLAM (idols) [a, PROPERTY DAMAGE Fb, PERSONAL WOURY Fc WRONGFUL DEATH {8 TAL Flr eam 100,000 100,000 [CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE INCIDENT ABOVE AND AGREE TO ACCEPT SAID AMOUNTIN a GRATURE OF GLAMAIT Ss ton eve "is PRONE OER OF PERSON SRNG FOR, DATE OF ERATURE ee TODAY" S BY: Girt Middle

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