Illinois > Secretary Of State > Court Of Claims
Property Damage Form - Illinois
| Property Damage Form Form. This is a Illinois form and can be used in Court Of Claims Secretary Of State . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 Property Damage Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) ) COURT USE ONLY Claimant ) Claim #: _______________________ ) Amount: _______________________ vs. ) ) Respondent, ) STATE OF ILLINOIS ) Claimant seeks from Respondent payment in the sum of $ _________________ ___ for property damage received as stated on the attached statement/narrative of events (with attached copies of bills, receipts, etc.), and made a part hereof asExhibit A. This property damage has resulted from the actions of the ________________________________________ Department, Board, Commissionof the State of Illinois. This is a claim in tort under the provisions o f Section 8(d) of the Illinois Court of Claims Act (705ILCS 505 etc seq.). 1. In support thereof, the Claimant states property damage as follows (att ach additional pages if necessary): ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ 2. ? The Claimant has not previously presented this claim to any State depart ment or officer thereof; or ? The Claimant did present bills in connection with this claim to ________ _____________________________ Department, Board, Commission on the _______________ day of ________________ , 20 ___ , and was referr ed to the Court of Claims for appropriate resolution. 3. The Claimant is the proper owner of this claim. 4. No assignment or transfer of this claim, or any part thereof or interest therein, has been made. 5. The Claimant is entitled to payment in the amount herein claimed from th e State of Illinois after allowing just credits. 6. The Claimant believes all the facts stated in this claim to be true. Printed by authority of the State of Illinois - March 2005 - 500 - CC-85 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 27. ? Neither this claim, nor any claim arising out of the same occurrence, ha s been presented to any person, corporation or tribunal other than the State of Illinois; or ? This claim was presented to _____________________ , a person, corporat ion or tribunal not affiliated with the State of Illinois, on the _______________ day of ________________ , 20 ___, with the following result: (Indicate payments, denials, etc. and attach copies of all documents.) ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ ________________________________________________________________________ ________________________________ 8. The Claimant further states that his/her Social Security Number is: ___ ___________________________________ _______________________________________________ Claimant Signature ________________________________________________ ________________________________________________ Claimant Claimants Attorney ________________________________________________ ________________________________________________ Street Address OR Street Address ________________________________________________ ________________________________________________ City State City State________________________________________________ ________________________________________________ ZIP Telephone Number ZIP Telephone NumberSubscribed and sworn to me this ____________________ day of ____________ _____________ 20 _____. ______________________________________________ Notary Public Procedures for Filing Property Damage Claims Against the State of Illinois 1. Complete the attached Court of Claims complaint form in its entirety, including your Social Security Number or your Federal Employee Identification Number (F.E.I.N.). 2. If you are represented by an attorney, complete the appropriate section of the complaint form so that all cor respondence may be directed to the attorney s office. An attorney is not required in order to file a Property Damage Claim. 3. Sign both claimant lines of the complaint form. Please print your name i n the space in between signatures. 4. A filing fee is required to file a Property Damage Claim ($15 for claims under $1,000; $35 for claims over $1,000). The filing fee must be included when the claim is submitted. 5. Collate the original complaint form, along with any itemized bills, invo ices, denial letters or other materials that substantiate your claim. Make five additional copies of the complaint form and attach the support ing documentation to each one of the complaint forms (original plus five copies of each document) and mail to: Illinois Court of Claims 630 S. College St. Springfield, IL 62756 Printed by authority of the State of Illinois - March 2005 - 500 - CC-85 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
