HomeMy WebLinkAbout*Other - Sheriff & JailGRANT COUNTY
COMMISSIONERS AGENDA MEETING REQUEST FORM
(Must be submitted to the Clerk of the Board by 12:00pm on Thursday)
REQUESTING DEPARTMENT: SIl@I'IffS Office
REQUEST SUBMITTED BY: John McMillan
. John McMillan
CONTACT PERSON ATTENDING ROUNDTABLE.
CONFIDENTIAL INFORMATION: EIYES -!OiNO
DATE- 11/25/2024
PHONE: 2017
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D.Agreement / Contract
EIAP Vouchers
FlAppointment I Reappointment
EIARPA Related
f-1 Bids / RFPs / Quotes Award
E]Bid Opening Scheduled
E]Boards / Committees
ElBudget
O'Computer Related
ElCounty Code
DEmergency Purchase
F-1 Employee Rel.
ElFacilities Related
WFinancial
DFunds
01-learing
ElInvoices / Purchase Orders
i7lGrants — Fed/State/County
01-eases
EIMOA / MOU
DMinutes
[10rdinances
00ut of State Travel
17 Petty Cash
7 Policies
,—Proclamations
17 Request for Purchase
F-1 Resolution
1-7 Recommendation
':]Professional Serv/Consultant
ElSupport Letter
E]Surplus Req.
[:,Tax Levies
E]Thank You's
E]Tax Title Property
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91IN4191-ifK4
Reimbursement for lost items for terminated employee - David De..aFoSa
-----------
Total Reimbursement $328.42
See attached
If necessary, was this document reviewed by accounting? ❑ YES 5-0 NO F N/A
If necessary, was this document reviewed by legal? L1 YES Fw-1 NO F-1 N/A
I
DATE OF ACTION: 1213
APPROVE: DENIED ABSTAIN
D1:
D2:
D3:
4/23/24
DEFERRED OR CONTINUED TO:
WITHDRAWN:
REG IVED
NOV 2 5 2024
GRANT C0U'NTY COTRAHS-SIONERS
INCIDENT INFORMATION (Cont"d)
10, If the Incident occurred on a street or highway:
Nam 6 of Street or highwayMilepost number At the intersection with or nearest intersecting street
11. Grant county agency or department alleged responsible for damage/injury:
r-t I
12. Names, addresses, and telephone numbers of all persons involved in or witness to this incident:
111 Names, addresses, and telephone numbers of all Grant County employees having knowledge about this
incident;
U7 -e
14. Narnes, addresses, and telephone numbers of all individuals not already identified in #12 and 913 above
that haVe knowledge regarding the liability issues Involved in this incident, or knowledge of the Claimant's
resulting damages, Please include a brief description as to the nature and extent of each person's
knowledge, Attach additional -sheets if necessary:
16. Describe the cause of the injury or damages. Explain the extent of property loss or rnedical, physical, or
mental 'Injuries. Attach additional sheets if necessary:
a a)
4t�54-
JAP"'. A 0 ro n e ckp r aae o\e 1-40- M W, /
116. Has the Incident been reported to law enforcement, safety, or security personnel? If so, when and to whom?
Grant Cbutity Standard Tort Claim Form
Last revised: July 2012
Page, 2 of 3
INCIDENT INFORMATIO Idl
17. Names, addresses, and telephone numbers of treating medical providers, Attach copies of all medical
reports and billings.
18. Please attach documents, which support the claim's allegations.
LI,2.... 0
19, 1 claim damages from Grant County in the sum of
This Claim form Mnust be 81191ned by the Claimant, a person holding a written power of att()rney from the
Claimant, by the attorney In fact for the Claima ' nt, by an attorney admitted to practice In Washington
Stato. on the Clalmanft behalf, or by a court -approved guardian or guardian ad 1111tem on behalf of the
Claimant.
I declare under penalty or perjury under the laws of the State of Washington that the foregoing is true and
correct
3o ke
Si6na-mire at Claimant .fat o and place (residential address, it and County)
Grant Coulity 84mdard Tort Claim Form Pagc3or- 3
List revised-. July 2012