NOTICE OF TORT 

To: Office of the director, 

Oregon Department of Administrative Services 

155 Cottage St N.E. U20 

Salem, OR 97301-3972 

CLAIMANT'S NAME 

CLAIMANT'S SJD. NUMBER 

CLAIMANT'S ADDRESS 

AMOUNT OF COMPENSATION DEMANDED 

D 

Pursuant to Oregon revised Statute 30.275 Claimant gives notice that a claim for damages is or 

will be asse1ted against the public body or an officer, employee or agent of the public body. Below is a 

description of the time, place and circumstances giving rise to the claim, so far as known to the claimant 

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If further infon~ation is desired I can be contacted at the above-indicated address. Any offer of a /, 

method of resolving my claim should be directed to me at the same address. 

NAMES AND ADDRESSES OF DEFENDANTS 

Oregon Depaiiment of Corrections 

2575 Center Street NE 

Salem, OR. 97310 

c/o 

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Page{JorY 

N . (}~ ._.\-l1 -~· ~---_(/ __ I __ Superintendent, 

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Form 27.010 

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