Free Form No. T-1 - North Carolina

North Carolina Industrial Commission

IC File # TN.C. Prisoner No.(if applicable)

CLAIM FOR DAMAGES UNDER TORT CLAIMS ACT
STATE OF NORTH CAROLINA COUNTY OF

AFFIDAVIT
, being duly sworn, deposes and says:
(Print Name of Claimant)

1. That his name is 2. That he lives at and that his mailing address is 3. That he hereby files a claim against
(State Agency or County Board of Education)

and that its mailing address is 4. That he has been damaged in the amount of $ named here
(Name(s) of negligent employee/agent)

by reason of the negligent conduct of the employee/agent .

5. That the injury or accident giving rise to this claim occurred at
(Print Name of County and Exact Location Where Accident Occurred)

on
(Month) (Day) (Year) (Time)

M.

6. That the injury or property damage occurred in the following manner:
(Give Brief Statement of What Happened, Names of Witnesses, etc.)

7. That the damages claimed above consist of
(Itemize Repair Bill, Medical Bills, etc.)

(Signature of Claimant)

(Date)

Subscribed and sworn to before me this

day of

.

My Commission Expires Signature and Seal of Clerk of Court or Notary Public FILE FOUR COMPLETE COPIES WITH THE INDUSTRIAL COMMISSION (If estimates of damages are submitted attach 2 copies) See Next Page for filing instructions

The North Carolina Tort Claims Act requires that every affidavit submitted must show ALL of the following: 1. The name of the claimant. 2. The name of the state department, institution or agency against which the claim is filed. 3. The name of the state employee upon whose alleged negligence the claim is based. 4. The amount of damages sought to be recovered. 5. The time and place where the injury occurred. 6. A brief statement of the facts and circumstances surrounding the injury. 7. If the claim involves a school bus, the claim should be filed against the particular COUNTY Board of Education concerned and NOT against the State Board of Education. 8. A claim for property damage to a motor vehicle must be in the NAME OF THE REGISTERED OWNER OF THE VEHICLE ONLY.

Mail to: North Carolina Industrial Commission Dockets Section 4336 Mail Service Center Raleigh, NC 27699-4336

FORM NCIC-T-1 2/01 PAGE 2 OF 2

FORM T-1

CLAIM FOR DAMAGES UNDER TORT CLAIMS ACT