Fillable TortClaim - Tort Claim Form

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TortClaim - Tort Claim Form

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File type: PDF

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WINTHROP UNIVERSITY TORT CLAIM FORM
DATE_________________ 2_____________
Person Making Claim:___________________________________________________
Claim is hereby made against _________________________________________
for damage resulting from occurrence.
DATE________________LOCATION OF OCCURRENCE_____AMOUNT CLAIMED
_________________ ADDRESS_________________ $_________________
TIME: ___________ COUNTY__________________ (Attach supporting
bills, estimates, other
documents
The cause of damage or injury was as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Reason you feel Winthrop University is legally liable:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
STATE OF SOUTH CAROLINA)
) AFFIDAVIT
COUNTY OF _______________)
Personally appeared before me _____________________________ who, upon
oath, says that the above claim is true, just, and that no part has been paid.
SWORN TO before me this ___________ day of
________________________20__________. ________________________
Claimant
____________________________________ ________________________
NOTARY PUBLIC Address
NOTE: The acceptance of this claim form does not constitute an admission of legal
liability on the part of the State or any other of its subdivisions or agencies.
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TortClaim - Tort Claim Form

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Completed 11 March 2020

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