ST9302-CL010411LAWSUIT/CLAIMS AGAINST THE CITY TRANSMITTAL FORM
DISTRIBUTION LIST: /
Jim Witt, City Manager
Bob Hager, City Attorney
b-'~ 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
CLAIM NOTICE (For Office Use Only)
[CLAIM NO. D q t I o t . I FILED IN
IMY OFFICE THIS THE I ]~ DAY. OF
/A-pt'il. , . ,2o0/
' i-/x..,'lA, g~, IK,e.r.fo r,
DEPUTY glTY SECRETARY
City Secreta~
City of Coppell (972) 304-3673 (FAX)
P.O. Box 478
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 1 day of APRIL ,2001 , at
approximately 1:00 o'clock PM , at the specific location of
DENTON TAPP 8, SANDY LAKE ROAOS , in Coppell, Texas.
2 The damage or injury occurred in the following manner:
DAMAGE TO TIRE FROM POT HOLE IN ROAD.
IMPACT DAMAGE TO RIGHT FRONT TIRE CAUSED BUBBLE ON OUTSIDE
OF TIRE TO FORM AND SPLIT INSIDE OF TIRE..
3. The full extent of my damages and/or injuries are as follows (be specific - attach estimates,
bills, etc. if available):
$101.91 FOR REPLACEMENT TIRE AND RELATED WORK.
COPY OF INVOICE #7343756 FROM DISCOUNT TIRI= CO.
ATTACHED. PHOTOS ATTACHED.
4, The amount of damages claimed is $ $101.91
(Please Print)
Claimant JAMES M. GORE Phone ~ 471-2839
Area Code
Addxess 524 LAYTON DR. City/State/Zip COPPELL, TX 75019 (Also list previous address if less than 6 months)
I do swear the above is tree and c,o~e)ct.
Signed ~-._~.~ ~/~'" _~ Date ~-//x/- t~) ? .
The notific~n shall~l~fil~d within~six'~) ~aonths of the date of injury or damage ~r, in the case of death, within s~ (6)
the da~...de~....th. The failure to so notify the City within the rime and manner specified shall exonerate, excuse and exempt t~e U~ty
from any liability whatsoever. (Article 11, Section 11.09 of the Home Rule Charter - Damage Stdts)
Revised 11/00