ST0301A-CL110103 NOTICE (For Office Use Only)
CLAIIVI NO. 4/ 02o// • / FILED EV
MY OFFICE THIS THE 2 n't „ I.) AY OF
ADM ISTRATIVE ECRE'FARY
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:
v.)
1. The injury or damage occurred on the day of , 20 at
approximately o'clock , at the specific location of
2 S b RoPt in Coppell, Texas.
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2. The damage or injury occurred in the following manner:
F l Bo8cFrr cAm o 0Q e ( 2 . 0 c . . r 2 - 1 - - ■ A O A- mab6a TJsr
a_ee. fQ037S (?.._PosTatil< 1 C,.-042 SLA%-t) . i C-40 c.a•
c-1 Ro 4-6 WA t cen 01,1 o0R- „_e4a°61
s.T - t -- E-ES &WC:PETE 9 - 1/20,547].
e2)J ou /2. P RoPE2--ry
3. The full extent of my damages and/or injuries are as follows (be specific - attach estimates,
bills, etc. if available):
j3V N cr■ t,
.. _
4. The amount of damages claimed is $ A Pro$. T _
(Please Print)
Claimant 1 S PA Phone ( 9/ ) _3 9 - 3 - I 5 L I 8
2 51,7 a•-Crii-i CD A 0-)Area Code
Address '7 BQ0 C-1 ST: City/State/Zip COPP E.tt_ -- Tze4 76D19
(Also list previous address if less than 6 months)
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I do swear the above is t e arkd co ct.
Signed Date
The notification all 0 tiled , ithin six (6) ionths of the date of injurN or damage or, in the case of death, within six (6) months of
the dale 01 death. The failure to so notify the City within the time and manner specified shall exonerate, excuse and exempt the City
from any liability whatsoeve, (Article 1 „Section 11.09 of the llome Rule Charter - Damage Suits)
Revised 06/03/02