SW0101-CS010531 LAWSUIT/CLAIMS AGAINST THE CITY TRANSMITTAL FORM
DATE:: 5 ',_5 I' OJ
CLAIMANT/PLAINTIFF: G ~* r ~* ~ ~~ ~
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
Garret Hoffman
CLAIM NOTICE .(For Oflqce Use Only~
!CLAIM NO. ~_~QL._J_ FILED IN
!MY OFFICE THIS THE _~1 DAy OF
DEPUTY CI'I¥ SECRETARY
City Secretary
City of Coppell (972) 304-3673 (FAX)
P.O. Box 478
Coppell, TX 75019
This is my notice of claim against the CiW of Coppell. The circumstances giving rise to this claim
are as follows:
1. The injury or damage occurred on the 2__~_ day of WIf"Ie ,20_OJ_., at
approximately 'ar o'clock ._~__, at the specific location of
11~~M,~1 ~q' , 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 $ J'flO. 85
(Pie&sc Print)
Claimant ~/~P-ll,~rr' }-~o~211,t~d Phone (~7~_) {~ 3 "' 1~.~
Area Code
Address //2 D~"~,,v~,'~ .~" City/State/Zip ~_~~ ~ -15'019
(Also list previous address if less than 6 months)
I do swear the above is true and correct.
· ' death. The failure t~. so notify the Cit3 within thc time and manner specified shall exone:-ate, excuse and exempt thc City
from any liability whatsoe~e~. (Article I I, Section 11.09 of the Home Rule Charter- Damage Suits)
Revised I! ~00