ST9302-CL 990112'C
The damage or '.injury occurred in the
The full' extent of my damages and/m
etc., if available):
The amount of damages claimed is $ ~
(Please Print)
Address ¢ ~'*
Date
I do swe~')the above is tree and correct.
NOTE: Article 11, Section 11.09 of the Hom Charter - Damage Suits. The notification shall be
filed within forty-five (45) days of the date of injury or damage or, in the case of death, within forty-five
(45) days of the date of death. The failure to so notify the City within the time and manner specified shall
exonerate, excuse and exempt the City from any liability whatsoever. No action at law shall be brought
against the City until at least sixty (60) days have elapsed following the date of notification.
CLAIM NOTICE
RECEIVED
(For Office Use)
PLEASE USE BLACK INK ONLY
CITY
CIW OF COPP~LL ~ CITY/SECRETARY
FILED IN MY
DAY OF
City Secretary
City of CoppeH
PO Box 478
Coppell TX 75019
This is my notice of claim against the City of Coppell.
follows:
The circumstances giving rise to this claim are as
The injury or damage occurred on the ~ ~ day of 0~.~~ , ~q ~,
at approximately $ o"clock ~ ._~, at the spe,~¢ location of
The damage or '.injury occurred in the following manner:
The full'extent of my damages and/or injuries are as follows (be specific - attach ~ifiaates, bills,
etc., if available): , .-.
The amount of damages claimed is $ J~
(Please Print)
Signed (~~~~ Date
NOTE: Article 1 I, Section 11.09 of the Home'Rule Charter - Damage Suits.
The notification shall be
filed within forty-five (45) days of the date of injury or damage or, in the case of death, within forty-five
(45) days of the date of death. The failure to so notify the City within the time and manner specified shall
exonerate, excuse and exempt the City fi-om any liability whatsoever. No action at law shall be brought
against the City until at least sixty (60) days have elapsed following the date of notification.
'~?FORDABLE
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INVOICE "'~'~× '~ 86500
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