CITY OF GREEN BAY-LIABILITY CLAIM FORM

SUMMARY: To file a claim against the City, you must comply with 893.80(1), Wis.Stats., which says yo must file a notice of claim with the City Of Green Bay within 120 days of the event from which you claim damages. You may use this form to file your claim.

ATTENTION: Filing a claim against the City does not automatically guarantee reimbursement from the City. Instead, the City examines each claim on an individual basis in determining if reimbursement is legally required. In order to obtain reimbursement for a claim against the City, you must prove that the City or its employees acted unlawfully or negligently. Only the City Attorney or the Commom Council and the Mayor can authorize payment of a claim against the City. Any other representations made by City employees are not legally binding on the City.

INSTRUCTIONS: Use the available areas on this form to fill in the requested information. Attach any documents that support your claim including receipts, invoices, estimates, government reports, etc. You may also mail it to or submit it in person to:

City of Green Bay -Claims, 100 N. Jefferson Street, Room 200 Green Bay, WI 54301
Claimant Contact Information
Circumstances of Claim and Relief Sought
Last/Business Name
*
Date of event
*
(H)     (M)
 
First Name
Address
Home/Cell
Work No
City
State
Zip
* Please provide specific names, Places,times, and facts when possilbe
Email
*
Confirm Email
    *          
Acknowledgment:         Date: 5/30/2017 2:21:28 AM             The Above information is complete, true and accurate to the best of my knowledge

Claimant Signature
*

* If submitting via online, type your full name on the line above to indicate you electronic signature