SS9402C-CS 961218LAWSUIT/CLAIMS AGAINST THE CITY TRANSMITTAL FORM
CLAIMANT/PLAINTIFF'
DISTRIBUTION LIST~
Jim Witt, City Manager
Peter G.Smith, City Attorney
Vivyon Bowman, Director of Human
Resources
Texas Municipal League
Lawsuit File (original/copy)
COMMENTS:
suit/city, form / -
revised 8/19/94
CITY SECRETARY, CITY OF COPPELL
P.O. BOX 478
COPPELL, TX 75019
(FOR OFFICE USE)
NO./.~/Y'~./ FI~
OFFICE, THIS T~ /~r~
Dear City Secretary:
This is my notice of claim against the City of Coppell.
giving rise to this claim are as follows:
1.
The ciro~!~tancan
2. The damage or injury occurred in the following intoner:
3. The full ext~nt: of my damage/[ and/or in!uries are as zo~M t?]/~ ~-~~-
s~cific; attach estmtes, bills, etc). ~_~ ~ ~ ~
4. The ~t of ~ge8 c~a~ i8 ~ ~ ~ ~,o ~
(Please Primt)~. _ ~ 6.
If you have resided at the above address less than 6 mmtha list
PREVIOUS ADDRESS
CITY/STATE
MOTE. ARTIC~ II, ~CTIGff 11.09 O~ T~ ~ RULE ~ - ~ SUITS.
Before the City of Co~Ull slmll be liable for any dmogex a claim droll bm
filed in uriting uith the City Becretmry within siz mmths after dexagex have
occurr~l, statim~ specifically ~mm, m amd how damm~ occurred, ~__~_ full
extant thereof, the ~ouat of damge8 clatmd, end the basis for liability on
tb part of the city.
REPAIR ORDER # : 25].37
DATE : 09/20/9~
PAGE 1 OF 1
CUSTOMER : SMITH, Si.IEiLA,, r, ~ - I VEHICLE : 1991 DATS 810/810
ADDRESS : 2605 BUCk ~.PJ~IL, LICENSE : FCS60C
CITY : E~ESS, TX 7~039 V.i.N. :
PHONE 1 : (817) 450-4592 EXT : ENGINE : 3.0 T~NS :
PHONE 2 : (972) 3~3-8206 EXT : MILEAGE : 99852
2.00 TRN10418 8ALL JOINT 8].96 ~ CHECK LEFT FR~T WHEEL,RATTLES NHILE~ 0.0,:
1.oo r~81882 STRUT 68.S~ ~ O~V[Ne,.tT POT ~OLE
1.00 HON81~l STRUT ~.5~ ~07 CS L~ER BALL JOINTS L~SE. REPLACED BOTH ~
5~.':'[
....... AL02 CS ~ NHEEL ALIGNHENT
SUBTOTAL ZZI.0~ C~1 CS REPLACED FReT STRUTS
, ~1 CS LOF 'LUBE ~ FIL~ANGE
~8TOTAL
[ am the person or agent acting on behatf of the person, who is rYotigated to
pay for the rel~ir of the motor vehicte subject to the repair contract.
understand that this vehicte is subject to rel~ossession i~ accordnnce with
9.503, Texas Business & Co~nerce C~e, if a written order for payr~nt for
repair on the vehicte i~ stopped, dishonored because of inaufficient funds,
no funds, or Decause the drawer or maker o~ the order has no account or the
account on which it is drawn ha~ keen close~.
MOT RESPONSIBLE FOR DAMAGE OR ART!CLES LEFT IN CAR iN CASE OF FIRE, THEFT OR
ANY OTHER CAUSE BEYOND ~:R CORTROL.hAZARDOUS WASTE CIIAR~E O# ALL REPAIR ORDERS
~0 DAYS OR 4000 NILES PAPTS & LABC~ ~AR~ANTY AT TH]$ FACILITY ONLY.
LABOR : $ 241.90
PART9 : ~ 221.04
SUBLET : $ 0.00
SHOP SUPPLI:$ 7.50
SUBTOTAL : $ 470.44
TAX/FEES : $ 18.52
TOTAL : $ 48~,96
PAiD : $ o.oo
DUE : $ 488.96