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2. Emergencies
   If this is a medical emergency, please call 9-1-1.
4. Making a Claim
   Use this form to make a claim for injury or property damage. This form is provided pursuant to state law (Government Code Section 910 et. seq.) and shall be used by any person presenting a claim to Vallejo Flood & Wastewater District under Government Code Section 810 et seq.
6. Contact Information
8. First Name*
9. Last Name*
11. Residential Address*
13. Residential Address-Line 2
15. City*
16. State*
17. Zip*
19. Mailing Address (if different)
21. Mailing Address-Line 2
23. City
24. State
25. Zip
27. Daytime Telephone*
28. Email Address
30. Evening Telephone*
34. The date, place, and other circumstances of the occurrence or transaction which gave rise to the claim asserted:
36. Date of Occurrence*
37. Time of Occurrence*
39. Place of Occurrence*
41. Circumstances*
43. General description of the loss, indebtedness, obligation, injury, or damage incurred so far as it may be known at the time of this claim:*
45. Name(s) of public employee(s) causing the injury, damage, or loss (if known)
47. Amount of Claim (only specify if claim is for less than $10,000.00)*
48. Would this claim be a Limited Civil case? ($25,000 or less)*

    1. Yes
    2. No
50. Bases for Computation*
    Specify particular expenses, estimated prospective injury, damage or loss, general damages, and so on. Please attach copies of bills and/or estimates, as appropriate.
52. Upload first document here
53. Upload any additional documents here
55. Upload any additional documents here
56. Upload any additional documents here
60. By typing in your name below and pressing the "Submit" button, you are making a claim and acknowledge that this is not a false claim. Submitting a false claim is a felony (Penal Code Section 72).*
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field