ST8505-CS 880922FILE COPY-
CLAIM NOTICE
City Secretary, City of Coppell
P.O. Box 478
Coppell, TX 75019
(FOR OFFICE USE)
CLAIM NO. C 0~3~ FILED
IN Y OFF C T IS THE
DAY OF .,~__~~,~ 19
~'-~:' CITY SECRETARY
Dear Sir:
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 ~
19 ~ at approximately ~:~ o'clock ~ , at the specific
location of ~ ~' ~ .~ in Coppell, Texas.
2. The damage or injury occurred in the following manner:
3. The full extent of my damages and/or injuries are as
follows (be specific; attach estimates, bills, etc., if available):
4. The amount of damages claimed is $ ~.~
(please print) ~ ~.~
CLAIMANT ~J ~a~g~ PHONE''~ Z-R~
I DO Sj~~~
SIGNED
TRUE AND CORRECT
NOTE:
ARTICLE 6252-19, SECTION 16, V.A.T.S. - NOTICE OF DEATH OR INJURY
"Sec. 16. NOTICE REQUIRED-Except where there is actual notice on
the part of the governmental unit that death has occurred or that
the claimant has received some injury, any person making a claim
hereunder shall give notice of the same to the governmental unit
against which such claim is made, reasonably describing the injury
claimed and the time, manner and place of the incident from which
it arose, within six (6) months from the date of the incident~
GINAL ESTIMATE .o. co.~.¢'I(~ NAME OF pERSON CONTACTE DATE CONTACTEDTIME ~'ONTACTED AT WRO DATE ~ LUBRICATE
~,, ~.C.~ [~ /'~' ~ ENGINE OtL
~..~.~o- ~ ~ CHANGE
reby grant your employees ~i~ion to opera~ t~ vehicle herein descried on ~~ AM P~ AM PM AIR CLEANER
eeTs. h*ghways 0r elsewhere for the purpose 0f t~tiflg and/or inaction. __ _ ~ k A T~ANS.S RVICE
JBdECT TO CONDITIONS ON REVERSE SIDE OF THIS CONTRACT'~~ (~[~ ~ ~~ AD .....
CUSTOMER ~KNOWLEDGES A COPY HEREOF
'v ' ~ BUs. PRONE
ff ?~ '/ :} DIS~ 0F WARRANTIES- Am, t~a"an:,es Oc the D'0~JCtS s0;d hereby are U .... LUBE
ARE BASED ON A RATE OF bi~+ty & ~t~cua' p%~s~ ~~', INC neither assume~ MINoRTUNE ENeINE
PER HOUR. ~*autho~yothe~rso~oa~s~o~F ~e~,onw~th~hesa~eo ~E ~ONE
,AN.. PART NUMBER DESCRIPTION PRICE
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/ ] OTS. OIL ~l //' '5' 2536 Forest Lane at LBJ
[ LBS. GREASE DALLAS, TEXAS 75234-6098
~ o. NO. SUBLET REPAIRS 214 - 247-7233 TAX
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