ST0003-CL080714CLAIM NOTIC]
City Secretary
City of Coppell (972) 304-3673 (FAX)
P.O. Bax 9478
,Coppell, TX 75019
For Uffce Use Only)
CLAIM NO. ~ ~ . ~ k"ILF.D IN
MY OFFICE HIS THE ~_,._. DAY OF
. ~, 2U.~~,..
~~~
ADMINISTRATIVE SECRE'CARY
This is my native of claim against the City of Coppell. The circumstances giving rise to this claim
are as follows:
~~
1. The injury ox damage occurred on the ~~.. day of ,-.._, 20_ , at
' loc at th ecific ovation of ~OJv
a roxnnately ~3 , D p ..... o c k ., ~ s~~
~1/¢/~~~ , in Coppell, Texas.
Z. The damage or injury occurred in the fallowing manner:
3.
oa
4. The amount of damages claimed is $.~~a~ ~'
(Please Print) ~e/~' ~/~. ~ 31 ~ - X18 ~
Claimant Y' - .~._ Phone ('~) ` ~,~ ~,~
Area Cod
r ''
Adaress ~`~'~ 17derson ~Q/~L° City/State/Zip l° l !.1~ '~' ~ ~_ 1
(Also list previous address if less than G months)
1 do swear the,~bove is~rrtte and correct.
Sign _ _ Date __~.~lQ- ~l~'~ --
The notific n a e fil! wit tin six (b) months ctf the date of injury or damage or, in the case of death, within six (b) months of
the date cif cath. The failure to sa notify the City within the tune and manner specified shall exonerate, excuse and exempt the City
from any liability whatsoever. (Article 1 l , 5cction t 1.09 of the Home Ttule Charter -Damage Suits)
Revised 06/03/02
The full extent of my damages and/or injuries arc as follows {6e specific -attach estimates,
bills, etc. if available):