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ELIZABETH BOARD OF EDUCATION NOTICE OF CLAIM FORM
PURSUANT TO N.J.S.A. 59:1-1, ET SEQ.
THE NEW JERSEY TORT CLAIMS ACT
1. Name of Claimant:______________________________________________________
Address: _______________________________________________________________
Social Security Number: __________________________________________________
2. Post Office Address to which Claimant desires notices and correspondence to be
sent:___________________________________________________________________
___________________________________________________________________
3. The date, School and/or location and other circumstances of the occurrence which gave
rise to the claim asserted herein:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4. General description of the injury, damage or loss incurred to date:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
5. The name(s) of the public entity/entities and/or employee(s) causing the alleged injury,
damage or loss if known:
_______________________________________________________________________
_______________________________________________________________________
6. The amount claimed as of the date of this form, including the estimated amount of any
prospective injury, damage or loss, as may be known at this time, with the basis of the
computation of this amount:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________