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Standard Tort Claim Form - OFM Number SF210

Pursuant to Chapter 4.96 RCW
This form is for filing a tort claim against the city of Aberdeen. Information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. Claims cannot be submitted electronically (via email or fax).
Print in Ink
Mall or Deliver Original Claim to:
Finance Director
City of Aberdeen
200 E Market Street
Aberdeen, WA 98520
Claimant Information
First Name
Middle
Last Name
Date of Birth
Current Residential Address
City
State
Zip Code
Mailing Address (if different)
City
State
Zip Code
Residential Address for Six Months Prior to the Date of the Incident (if Different from Current Address):
City
State
Zip Code
Claimant's Daytime Telephone Number:
Home Number
Business Number
Claimant's Email Address
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Incident Information
Date & Time of Incident
Date & Time of Incident Start Date
Date & Time of Incident Start Time
—
Date & Time of Incident End Date
Date & Time of Incident End Time
Address of Incident
City
State
Zip Code
Names, Addresses and Telephone Numbers of All Persons Involved in or Witness to This Incident
Names, addresses and telephone numbers of all individuals not already identified that have knowledge regarding the liability issues involved in this incident, or knowledge of the Claimant's resulting damages. Please include a brief description as to the nature and extent of each person's knowledge. Include additional sheets if necessary.
Describe the cause of the injury or damages. Explain the extent of property loss or medical, physical or mental injuries. Include additional sheets if necessary.
Has this incident been reported to law enforcement, safety or security personnel? If so, when and to whom?
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Additional Information Required for Automobile Claims Only
License Plate Number
Drivers License Number
Make, Year, & Model of the Vehicle
Driver Name
Driver Address
City
State
Zip Code
Drivers Phone Number
Passenger Names
Passenger Address
Owner Name
Owner Phone Number
Passenger Names
Passenger Address
Owners Address
City
State
Zip Code
Names, addresses and telephone numbers of treating medical providers. Attach additional sheet if necessary. Attach copies of all medical reports and billings.
Please attach any additional documents which support the claim's allegations.
I claim damages from the city of Aberdeen in the sum of
Signature
The Claimant must sign this form unless he or she Is Incapacitated, a minor, or a nonresident of the state, In which case it may be signed on behalf of the Claimant by any relative, attorney, or agent representing Claimant. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Signature of Claimant
Date & Place (Residential Address, City & County)

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