3512.2b – Business – Business – Personal Property Reimbursement Claim

Policy –
Regulation –
Exhibit – x

Adopted – 7/1/1999
Revised –
PERSONAL PROPERTY REIMBURSEMENT CLAIM

Request is hereby made to the District for reimbursement for my property loss.

Name: ________________________________ ___ Position: ______________________________
Home Address: ___________________________ Home Phone: _________________________
__________________________________________
Campus/Office: __________________________ Work Phone: __________________________

Description of property: ____________________________________________________________
____________________________________________________________________________________
Description of loss (details of actual loss, place, date, time, and other pertinent details): ____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
How did loss occur:_________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Loss reported to: Security __________ Police __________ Other ___________________

Witnesses (names/addresses/phone numbers):
____________________________________________________________________________________
____________________________________________________________________________________
Party causing loss (if known): _______________________________________________________
____________________________________________________________________________________

Amount of loss $ _______________ (attach copy of approved Exhibit 3512.1a)
Amount covered by personal insurance $ __________________

I certify all statements to be true and claim the above amount as full reimbursement. I further certify that I have exhausted all other means of reimbursement reasonably available to me. If the claim is allowed, I hereby subrogate to the District any right to recover compensation for such damaged property.

Signature: ___________________________________ Date: __________________________

Certification of Supervisor: I believe the above to be a true and accurate statement of facts: Signature: ____________________________ Date: __________________________

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FOR BUSINESS USE ONLY
Determination made by District: ____________________________________________________

CSBA Date –

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