Appendix C
Sample Application to File a Late Claim

Claim of _____[name]______  ) APPLICATION FOR LEAVE
                            ) TO PRESENT LATE CLAIM
against                     ) Govt C ( §911.4)
                            )
___[name of entity]_________)
____________________________)

To the Board of Supervisors (or other governing body) of ____[name of entity]________:

1. [Your name] hereby applies to the County of _______ for leave to present a claim against the County of ___________, pursuant to Section 911.4 of the California Government Code.
2. The cause of action of [your name] as set forth in his/her proposed claim attached to this application, accrued on _________, 20__, a period within one year from the filing of this application.
3. [Your name]’s reason for the delay in presenting his/her claim against the County of ____________ is as follows: [specify facts justifying delay in filing the claim].
4. All notices and communications concerning this claim should be sent to ____[your name & address]_____________________.

[Printed Name]

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