Form SFN50552 "State Risk Management Fund Notice of Claim" - North Dakota

What Is Form SFN50552?

This is a legal form that was released by the North Dakota Office of Management and Budget - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2019;
  • The latest edition provided by the North Dakota Office of Management and Budget;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN50552 by clicking the link below or browse more documents and templates provided by the North Dakota Office of Management and Budget.

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Download Form SFN50552 "State Risk Management Fund Notice of Claim" - North Dakota

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STATE RISK MANAGEMENT FUND NOTICE OF CLAIM
RISK MANAGEMENT DIVISION
SFN 50552 (08-2019)
Name of Claimant/Property Owner (First, Middle, Last)
Home Address
City
State
ZIP Code
Contact Number
Email
Date of Incident
Time of Incident
Place
Name of state or agencies and state official(s) or employee(s) involved
Description of the incident
Description of the injury or loss
Dollar amount of injury or loss claimed: please attach any documentation (e.g. medical bills, repair invoices, estimates, etc.)
I hereby swear or affirm that the facts stated above concerning this claim against the State of North Dakota its agencies, officials, or
employees are true and correct. Please complete.
Signature of Claimant(s)
Date
STATE OF
COUNTY OF
Signature of Notary Public
Commission Expiration Date (if not listed on stamp)
N.D.C.C. § 32-12.2-04 provides that a person bringing a claim against
Affix Notary Stamp
the state or a state employee for an injury shall present written
notice to the director of the Office of Management Budget within
one hundred eighty (180) days after the alleged injury is discovered
or reasonably should have been discovered.
If your claim is for property, please enclose at least two estimates
Mail to: Director of OMB; Risk Management Division
for the damages with your completed claim form.
1600 E. Century Ave., Suite 4; Bismarck, ND 58503
Telephone: 701-328-7584 Fax: 701-328-7585
Email:
rminfo@nd.gov
STATE RISK MANAGEMENT FUND NOTICE OF CLAIM
RISK MANAGEMENT DIVISION
SFN 50552 (08-2019)
Name of Claimant/Property Owner (First, Middle, Last)
Home Address
City
State
ZIP Code
Contact Number
Email
Date of Incident
Time of Incident
Place
Name of state or agencies and state official(s) or employee(s) involved
Description of the incident
Description of the injury or loss
Dollar amount of injury or loss claimed: please attach any documentation (e.g. medical bills, repair invoices, estimates, etc.)
I hereby swear or affirm that the facts stated above concerning this claim against the State of North Dakota its agencies, officials, or
employees are true and correct. Please complete.
Signature of Claimant(s)
Date
STATE OF
COUNTY OF
Signature of Notary Public
Commission Expiration Date (if not listed on stamp)
N.D.C.C. § 32-12.2-04 provides that a person bringing a claim against
Affix Notary Stamp
the state or a state employee for an injury shall present written
notice to the director of the Office of Management Budget within
one hundred eighty (180) days after the alleged injury is discovered
or reasonably should have been discovered.
If your claim is for property, please enclose at least two estimates
Mail to: Director of OMB; Risk Management Division
for the damages with your completed claim form.
1600 E. Century Ave., Suite 4; Bismarck, ND 58503
Telephone: 701-328-7584 Fax: 701-328-7585
Email:
rminfo@nd.gov