ST9302-CL03102109/~2/2003 10 ~ S6 ~
City Secretar~
Cit~ of Col~sll (972) 304-3673 (FAX)
P.O. Box 9478
Coppell, TX 75019
This is my notice of claim against the City of Coppell. The circumslances g~vin§ n~e ~o this cla~m
ale as foilow~: ed on the day of [kJ/A -- ,20 , at
2. The damage o~ injury occu~ed i~ the following manner'.
3, The full extent of my damages and/or injuries are as follows (be specific - attach estimates,
bills, etc. ff available)~.
<~
13_
0
0
U