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Claim Request Form

The undersigned submits the following information and makes claim against the City of Nogales as follows:

1.CLAIMANT INFORMATION

2.OCCURENCE OR EVENTS GIVING RISE TO THE CLAIM

3.DESCRIPTION OF PROPERTY DAMAGE AND INJURIES

4.WITNESSES

5. Are there any additional comments, details or information you want us to consider in responding to your claim?

6. By signing you verify the information presented in this claim is try to the best of your knowledge and belief.

7. Notice of Claim received by: (To be filled by City Staff)

Please fill in ALL INFORMATION requested above or your notice of claim may be deemed defective. All notices must be signed and dated. City must also indicate above, the date and time received.

THE ARIZONA MUNICIPAL RISK RETENTION POOL AND SOUTHWEST RISK SERVICES ARE NOT AUTHORIZED AGENTS TO RECEIVE ANY NOTICE OF CLAIM UNDER A.R.S. §12-821.01. ALL NOTICES OF CLAIM MUST BE LEGALLY SERVED ON THE CITY AND, ON EACH INDIVIDUAL WHOM YOU CLAIM TO BE RESPONSIBLE FOR YOUR INJURIES OR DAMAGES.

THIS FORM WAS CREATED FOR YOUR CONVENIENCE. HOWEVER, THE CITY THAT IS PARTY TO THIS MATTER DOES NOT WAIVE ANY OF ITS RIGHTS OR DEFENSES FOR YOUR FAILURE TO COMPLY WITH ALL NOTICE OF CLAIM REQUIREMENTS ESTABLISHED BY ARIZONA STATUTE AND LAW. UNDER A.R.S. §12-821.01, YOU ARE REQUIRED TO STATE YOUR DAMAGES WITH A SPECIFIC DOLLAR AMOUNT FOR WHICH YOU WILL SETTLE YOUR CLAIM AND, TO SUPPORT THAT AMOUNT WITH EVIDENCE. YOUR NOTICE OF CLAIM WILL BE DEEMED DEFECTIVE WITHOUT THIS INFORMATION. FILING A VALID NOTICE OF CLAIM IS ALWAYS YOUR SOLE RESPONSIBILITY.

City of Nogales

Residents make Nogales a great place to live, work, play, and visit.

Mayor John Doyle

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  520-287-2230
  777 N. Grand Ave
   Nogales, AZ, 85621

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