MA1001-CL100707CLAIM NOTICE (For Off ice Use Only)
CLAIM NO. `l (FILED IN
MY OFFICE THIS THE -.Cj:J_ DAY OF
, 20 - -.-
A -
ADMINISTRATIVE S ECRETARY
City Secretary
City of Coppell (972) 304 -3673 (FAX)
P.O. Box 9478
Coppell, TX 75019
This is my notice of claim against the City of Coppell. The circumstances giving rise to this claim
are as follows:
1. The injury or damage occurred on the J day of _ .... _ .... _ ..... _ , 20_[x, at
approximately _. — o'clock �— , at the specifi location of
0- o _
2. The damage or injury occurred in the following manner:
C
in Coppell, Texas.
3. The full extent of my damages and /or injuries are as follows (be specific - attach estimates,
bills, etc. if available):
vdG l
4. The amount of damages claimed is $ 1 U 0 __ __
(Please Print) -W 1 05-
Claimant - Cdr Phone (Z C2 fl d s
/ AO L) f b i to � Area Code
Address C&1i6 11- 40k+ 1 X 7S0 ly City /State /Zip G f (0 1J0
(Also list previous address if less than 6 months)
I do swear the above is true and correct.
Signed Date._ 6
The notificatio shall be file within six (6) months of the date of injury or damage or, in the case of deat Evithin six (6) months of
the date of de' h. The failure to so notify the City within the time and manner specified shall exonerate, excuse and exempt the City
from any liability whatsoever. (Article 11, Section 11.09 of the Home Rule Charter - Damage Suits)
Revised 06/03/02
170 EaM Country Ridge
Lewme, TX 75067
972- 19s� 9 M'6 i eie#hone
972 -1-7071 Fax
ustomer InIMMUNWH
Date; 07/07/2010
Customer Nam 14ARIE AMODEO
I nvoice - , 3995 Address: 2044k W VEBRON PK # 3526
City: C State: TX Zip: 75010
Phone: 972 -&AS- 71579
VIN: 3N 1 ADAL609478
YEAR/MAKE/4%,WDEL: 2010 NISSAN SENTRA
Inspecl9iWo of Vehicle Description
Total
1— REMOVE RED PAINT FROM FRONT OF THE CAR AND MIRRORS
P,
5 a
A STORAGE FEE WILL BE CHARGED SEVENIIT NVD HOURS AFTER
.
REPAIRS ARE COMPLETED. IF LEGAL ACTXof3! IN NECESSARY TO
ENFORCE THIS CONTRACT, YOU WILL BE R EMPttt5_NSIBLE FOR ALL
ATTORNEY'S FEES AND COURT COSTS.
•
5 4
y �r
I hereby authorize repair work to be done by 21stt 0mitury Collision Repair
1�t++�1
'. W ., t
� �� �R
Center. An express mechanic's lien is acknowledgWI wri time above vehicle to
secure the amount of repairs thereto. I will not be heldl atmponsible for loss or
damage to vehicle in case of fire, theft, accident or amp otfner cause beyond my
control.
$ 100.00
CUSTOMER SIGNATURE
Co lliio,n