Diminution Claim Form

DIMINUTION CLAIM FORM

This Diminution Claim Form (the "Form") is submitted by Claimant Name: and is directed to Respondent Name: concerning Property Address: .

RECITALS

WHEREAS, Claimant is the owner or an authorized representative of the real property identified above and asserts that the fair market value of the property has been reduced as a direct result of the Event described herein; and

WHEREAS, Respondent is the party alleged to be liable for compensation for diminution in value, whether as insurer, acquiring authority, responsible party, or other obligated entity; and

WHEREAS, the parties desire to document the Claim for diminution in value and to provide the information required for assessment and resolution.

NOW THEREFORE

In consideration of the mutual covenants and agreements set forth in this Form, Claimant and Respondent agree as follows:

1. DEFINITIONS

For purposes of this Form: "Claim" means the assertion of diminution in fair market value set forth herein; "Property" means the real property identified above; "Event" means the occurrence or condition alleged to have caused diminution; "Diminution" means the difference between the fair market value of the Property immediately prior to the Event and the fair market value immediately after the Event, determined in accordance with the valuation methodology selected in Section 4.

2. CLAIM SUBMISSION DETAILS

Date of Event:    Claim Reference Number (if any):

3. PROPERTY AND APPRAISAL DATA

Appraiser Name:    Appraisal Firm:

Appraisal Date:

Fair Market Value Prior to Event: $    Fair Market Value After Event: $

Diminution Claimed (difference): $

4. VALUATION METHODOLOGY

Select the valuation method(s) used to determine diminution (check all that apply):

Sales comparison / market approach    Income approach    Cost approach    Agreed value or stipulated loss

5. SUPPORTING DOCUMENTATION

The following documents are submitted in support of this Claim (check all that apply):

Appraisal report    Photographs pre- and post-event    Recent closing statement or settlement statement    Inspection reports

6. CALCULATION OF DAMAGES

Total Diminution Claimed: $

7. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that the information and documents submitted with this Form are true, accurate, and complete to the best of Claimant's knowledge; that the appraisal(s) attached were prepared in conformance with applicable professional standards; and that Claimant is authorized to submit this Claim. Claimant agrees to provide additional documentation or permits further inspection upon reasonable written request by Respondent.

8. AUTHORIZATION TO INVESTIGATE

By submitting this Form, Claimant authorizes Respondent and its agents to obtain records, reports, or other information relevant to the Claim, including appraisal files, inspection reports, and sales history, and further authorizes third parties to release such information. This authorization shall remain in effect for the duration of the Claim review.

Authorization Granted:

9. INDEMNITY AND LIMITATION

Claimant shall indemnify and hold Respondent harmless from claims arising from false statements, intentional misrepresentations, or willful submission of fabricated documentation. Respondent's liability, if any, shall be limited to the diminution in fair market value demonstrably caused by the Event and as supported by the valuation methodology and documentation submitted hereunder, subject to any offsets, credits, or applicable deductibles.

10. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses below by certified mail, courier, or personal delivery and shall be effective upon receipt.

11. AMENDMENTS; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver thereof. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form shall be governed by and construed in accordance with the laws of the State of: , without regard to its conflict of law principles. This Form constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior negotiations, understandings, and agreements. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

13. CERTIFICATION

By signing below, Claimant certifies under penalty of perjury that the statements made herein are true and correct to the best of Claimant's knowledge and that the supporting documents provided are authentic and complete. Claimant further acknowledges that submission of materially false information may result in civil or criminal penalties.

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