ST0202-CS040211Ti.is is my notice of claim against the Clty of Coppell. The circumstances giving rise to Lf'lis claim as follow~: ~
e tn' or damage occurred on the _____. ¥ ~V.L' n f ~
'Fine damage or inJury~ccurrcd in
The full extent of my damages and/or injtu-ie$ arc as follows (be spcci~c - arcaclt estimates,
The amount of d&mages claimed is $
Addxess _
(Also list previous address if less than 6 months)
, City/Sta{e/ZiP ~
City Secre[a~
City of Coppell
PO Box 9478
(972) 304-3673 (FAX)
MY OFFICE THIS TI~ _ .- ~r.-- ,-,- I
~ y
Coppel~, TX 75019
Ti,as is my notice of claim against ac City of Coppell. The ckcumstances giving rise to this claim
!. ~:r iloxJ~yd~_mage ° ccu~dcl
as -pp
The damage or mJury:~
The full extent of my damages and/or injuries are ~s follows (be specific ~ attach estimates,
bills, etc. ffavailable):
The amount ord~mages claimed is $
Ad&ess __ , , Ci~lState/Zip ..... (ALso List previous ad&ess if les~ than 6 months)
I do swear th,.e, above is t~e and correct.
~ignea . 'f-'.
ed. ,~tb~ SLx (6) months of t~ d~le o~ mJo. rY ~,r ~s",, '"~'-
from ~y ~ ~a~- (~e Il, S~an ] 1 o~ ott~ nome