RESOLUTION 2007-42

(Amend Resolution 2001-32 and 2001-48 to add requirement of county claim form to be completed)

WHEREAS, Skamania County feels that it is in the best interest of Skamania County that a form be created to be used when filing Claim For Damages or Tort Claims against Skamania County.

NOW, THEREFORE, BE IT RESOLVED that a form shall be created and may from time to time be changed as it becomes apparent additional information is necessary; and

BE IT FURTHER RESOLVED that the Board of County Commissioners require that the attached document entitled “Skamania County Claim For Damage Form” be used when filing claims against Skamania County; and

BE IT FURTHER RESOLVED all claims shall be filed with the Skamania County Auditor at Skamania County Courthouse, 240 NW Vancouver Avenue, Room 27, Stevenson, WA 98648 between the hours of 8:30 a.m. and 5:00 p.m.

BE IT FINALY RESOLVED, that this resolution shall be recorded with the County Auditor

PASSED IN REGULAR SESSION this 23^rd day of October, 2007.

SKAMANIA COUNTY CLAIM FOR DAMAGE FORM

CLAIMANT: THIS CLAIM MUST BE FILED WITH THE FOR OFFICE USE ONLY:

SKAMANIA COUNTY AUDITOR’S OFFICE CLAIM NO.___________________

Skamania County Courthouse

P.O. Box 790 DATE FILED:_________________

240 NW Vancouver Avenue, Room 27

Stevenson, WA 98648 COPIES TO:__________________

NO DAMAGES CAN BE PAID BY SKAMANIA COUNTY UNLESS THIS

FORM IS COMPLETE. THIS PROVISION CANNOT BE WAIVED. ATTACHMENTS: YES(#___) NO

1. Name (including spouse if married): (Please Print)

________________________________________________________________________

2. ________________________________________________________________________

Address City State Zip

3. HM Phone:____________ WK Phone:______________ MSSG Phone:____________

4. Date and time of incident:__________________________________________________

5. Location of incident:

________________________________________________________________________

6. Describe in narrative form and in detail exactly how the incident occurred:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. What is the amount of damages claimed arising out of the following circumstances

(Include estimates and bills, if available):____________________________________

_______________________________________________________________________

8. Please list name and address of any and all witnesses or persons involved:

(Please Print)

________________________________________________________________________

9. Describe the damages or injuries you sustained as a result of the incident:_________

10. Was incident investigated by a police officer? Sheriff_______ State Patrol_____

City__________________________

11. If a vehicle was involved in the incident, describe: Make_______________________

Model______________ Year________ State_____ License No._________________

Insurance Company __________________ Policy Number____________________

12. Describe what you did after the incident occurred:_____________________________

13. Describe the conversations you had, if any, with County personnel during or after

the incident occurred._____________________________________________________

________________________________________________________________________

14. How did you identify the County as the party responsible for your damage?

________________________________________________________________________________________________________________________________________________

I certify under penalty of perjury under the laws of the State of Washington that the information contained in this claim is true and correct.

DATED THIS _____DAY OF ________________, 20___

_____________________________

Claimant’s Signature

File Name: Commiss/Risk Mang/Claims/Claim For Damages

NOTE: Personal property (car, etc.) damages are to be accompanied by 2 estimates for repair costs. The Skamania County Risk Manager will investigate this claim. The decision to honor this claim will be based upon that investigation. Making a false report or providing false evidence is a crime and punishable by fine and/or imprisonment. Additional pages may be attached if needed to answer the questions.