MA 09/10-CL1101282011) Keith Marvin -Claim received Page 1
From:
Christa Christian
To:
Keith Marvin
Date:
1/28/2011 1:52 PM
Subject:
Claim received
Attachments:
D00012811. pdf
Attached is a copy of the claim.
>>> "in603O" < copier @ci.coppell.tx. us > 1/28/20114:39 PM >>>
Scanned from MFP- 05868788.
Date: 01/28/2011 14:39
Pages:3
Resolution: 200x200 DPI
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Scanned document from Oce 6030 copier
CLAIM NOTICE
Office Use
CLAIM NO. 4/2 /.l._._..._.FILED 1N
MY OF ICE THIS THE 2 7 DAY OF
SECRETARY
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 day of , 20l, at
approximately ' o'clock . , at the specific locaAon of .�_
a W A �ne,� . CQ,a�n _��, - - -- , in Coppell, exas.
2. The damage or injury occurred in the following manner:
0VL6A ✓ ° e-oy - +1
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(Please Print)
�oc I's
�- c0�"�ivkta
Claimant kvq TC vQ Phone ()
Area Code
Address 513 City/ State/ Zip l _._.�re- TX__ 7 5DL I
(Also list previous address if less than 6 months)
I do swear the above is true and corrcc
Signed Date
The notiFication atl filed within six e ca
(6) mont date of injury or damage or, in thse �,Fdeath, within six (6) months of
the date of de th. e failure to so notify the City within the time and manner specified shall exonerate, excuse and exempt the City
from any lialdility whatsoever. (Article 11, Section 11.09 of the Home Rule Charter - Damage Suits)
Revised 06103/02
The full extent of my damages and /or injuries.are as follows (be specific - attach estimates,
bills, etc. if available):
The amount of damages claimed is $ 404,51
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