ST9302-CL010531 LAWSUIT/CLAIMS AGAINST THE CITY TRANSMITTAL FORM
DATE" ~...~ - 3 } '(~ ]
DISTRIBUTION
LIST:
/",, Jim Witt, City Manager
Bob Hager, City Attorney
Vivyon Bowman, Director of HR
Texas Municipal League
Lawsuit File (original/copy)
COMMENTS:
\\TWN_CTR\USERS\Kwilkers\Claim Forms\Suit Transmittal Form.doc
Revised 8/19/94
05/29/01 15:24 CITY DF COPPELL ~ MOL Ga~ ~, I~ . NO.?S1 P001
_C_LAIM NOTICE (For Office Use OnIl0..
CLAIM NO. ~ $ l ?O0~'.~r'~ILED IN
MY OFFICE~I~IIS THE .._~q I DAY OF
'.
DRPUTY CITY .~I~.C'R~'I'A~Y
Ci~ Or Cop~ (972) 3~-3673 (FAX)
P.O. Box 478
Cop~, TX 75019
~is is my notice orclaim a~amst the Ci~ of Cop~ll. The c~cumstances giv~g risc to this claim
t. Thc ~ju~ or ~ma~ oc~d on ~hc day of x ,2~/, at
a~rqxima~ly,~ ~--~~~~~ o'ff[~~ ~., at the sp~ific ioca~i~ of .......
2. ~c damase ar ~ju~ occu~ed ~ ~e followEE ~nncr:
3. The full extent ofmy da~ges and/or injuries ~e as fo~ows ~e specific, attach estimates,
b~s, etc. if ava~ble):
Claim~t ~~ ~~~~ Phone(
I do swear~e abo~e is ~ue and co~t. , --
Rcwlld ] II~0