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2. 
4. City of Jenks
   PO Box 2007
   211 N Elm St Jenks, OK 74037
   918-299-5883
6. The filing of this form with the Jenks City Clerk's office is only the initial step in the claim process and does not indicate in any manner the acceptance of responsibility by the City of Jenks or its related entities. This form is required by law and shall be filed with the City Clerk within one (1) year from the date of occurrence. Failure to file within such time frame may result in the claim being barred in its entirety.
8. Name of Claimant
9. Address
11. Day telephone
12. Night telephone
14. Email address
16. Date of occurrence
17. Time of occurrence (include a.m./p.m.)
19. Location of occurrence
21. Names of Witnesses to Occurrence (list address and phone if known)
23. Was the occurrence reported to any City department?*

    1. Yes
    2. No
25. If yes, give name of department, employee, and date reported.
27. Total dollar amount of claim
28. Please attach documents supporting claimed amount
30. List briefly the claimed damage to person or property.
32. Were any other parties involved? If so, please state the nature of their involvement, whether they were at fault to any degree, and whether they sustained injuries or damages.
34. Use this space to describe completely the occurrence and events just prior to and immediately afterword.
36. Thank you for submitting your governmental tort claim. We will investigate your claim promptly. Under Oklahoma law, the City has 90 days from receipt of your claim within which to approve or deny. Please understand that investigating your claim involves the coordination of an investigation with multiple departments and often the City’s insurer. Please do not contact us to check on status, we will contact you as soon as a decision is made or if we need more information. If we fail to respond within 90 days of the date you submitted your claim in writing, the claim is deemed denied.
38. Electronic Signature Agreement

    By checking the "I agree" box below, you agree that you have read the above statement. You also acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
40. Electronic Signature
41. Date
    Date
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field