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Get NC Form NCIC-T-1 2001

S and says: (Print Name of Claimant) 1. That his name is 2. That he lives at and that his mailing address is 3. That he hereby files a claim against (State Agency or County Board of Education) and that its mailing address is 4. That he has been damaged in the amount of $ by reason of the negligent conduct of the employee/agent . named here (Name(s) of negligent employee/agent) 5. That the injury or accident giving rise to this claim occurred at (Print Name of County and Exact Location Where.

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