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The document is a Notice of Claim form that must be filed against the State of Arizona in accordance with A.R.S. §12-821.01. It requires claimants to provide personal information, details about the incident including date, location, and circumstances of the claim, as well as the amount being claimed. The claim must be submitted within 180 days of the incident and should include supporting documents.
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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling out the 'Claimant Information' section. Enter your name, address, city, state, zip code, and contact numbers. Ensure all fields are completed legibly.
  3. In the 'Facts' section, provide details about the date and location of the occurrence. If applicable, include specific information for roadway claims such as time of occurrence and direction of travel.
  4. Describe the circumstances surrounding your claim in detail. Include any relevant state agency information and attach additional pages if necessary.
  5. Specify the amount of your claim in dollars. Remember that a valid claim must include a specific settlement amount as per ARS 12-821.01.
  6. Sign and date the form at the bottom before submitting it to ensure its validity.

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