Fill and Sign the North Carolina Tort Form

           COUNTY OF             1. That his name is       2. That he lives at       and that his mailing address is       3. That he hereby files a claim against       and that its mailing address is       for damages resulting from the negligence of       4. That he has been damaged in the amount of $       5. That the injury or accident giving rise to this claim occurred at                                     6. That the injury or property damage occurred in the following manner:             7. That the damages claimed above consist of                   IN TESTIMONY WHEREOF, the said       hand and seal, this                   this                   My Commission Expires       FORM NO T-1 NORTH CAROLINA INDUSTRIAL COMMISSION I.C. FILE NO. T- N.C. PRISONER NO.- RALEIGH (If applicable) CLAIM FOR DAMAGES UNDER TORT CLAIMS ACT, G.S. 143-291 et. seq. STATE OF NORTH CAROLINA AFFIDAVIT , being duly sworn, deposes and says: (Print Name of Claimant) (State Agency or County Board of Education) (Print Name of Employee or Agent Involved) by reason of the negligent conduct of the employee agent named above. (Print Name of County and Exact Location Where Accident Occurred) on , , at (Month) (Day) (Time) (Give Brief Statement of What Happened, Names of Witnesses, etc.) (Itemize Repair Hill, Medical Bills, etc.) (Name of Claimant) has hereunto set his day of Subscribed and sworn to before me (Signature of Claimant) day of 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 reverse side of form for filing instructions The North Carolina Tort Claims law 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, claim should be filed against the particular COUNTY Board of Education con- cerned and NOT against the State Board of Education. 8. Claim for property damage to a motor vehicle must be in the NAME OF THE REGISTERED OWNER OF THE VEHICLE ONLY.