Willowood-CS 961030CITY SECRETARY, CITY OF COPPELL
P.O. BOX 478
COPPELL, TX 75019
Dear City Secretary:
Thii is ~Y notice of clal~ against the City of Coppell. The circu~tancaI
givinq riie to thiI clal~ are as follmm:
1. Date injury or ~ occurred {i/dd/~)10/~7/% ~t~) ~: ~s --~
2. The da-~ge or injury occurred in the following ~asnar:
'
I~cific; attach iIt~t~, ~illI, etc):
4. The a~ount of d · clai~d il I J" [~'~
(Please Prin/~) d ~
If you have resided at the above address less than 6 eont~ list
pREVIOUS ~DDRES$ CITY/STATE
all da~e3.
ALBERTSONS
IT'S YOUR STORE!
10/28/96 09:40 4115 06 0060 122
4e.50 BAKING SODA 2.00 F
FRESHNER 2.50 T
FRESHNER 2.50 T
FRESHNER 2.50 T
LAUNDRY DET 10.99 T
AIR F~? ~cR 2.50 T ~
PS CqJL< 9.99 T
LYSOL 4.69 T
**** TAX 2.76 GAL 40.43
VF 0 CHECK 40.43 0
~OTAL NUMBER OF ITEMS SOLD ' 11
THANKS FOR SHOPPINO WITH US!