Claims for death, injury to person or personal property must be filed no later than 6 months after occurrence (Govt. Code Sec. 911.2).

Claims for damage to real property must be filed no later than 1 year after occurrence.

Knowingly filing false claims violates Govt. Code Sec. 12650 and Penal Code Sec. 72 and can be prosecuted as fraud.

You must provide a response to each question, if it does not apply please write N/A. You may attach additional documents to provide details.

You must sign the claim form at the bottom of page 2.

Deliver or mail to: Rubidoux Community Services District 3590 Rubidoux Blvd. Jurupa Valley, CA. 92509 (Govt. Code Sec. 915a.).