ST9302-CL000921LAWSUIT/CLAIMS AGAINST THE CITY TRANSMITTAL FORM
DATE:
FROM:
U
CLAIMANT/PLAINTIFF'
DISTRIBUTION LIST:
Jim Witt, City Manager
Peter G.Sm~th, City Attorney
Vivyon Bowman, Director of Human
Resources
Texas Municipal League
COMMi NTS:
suit/city.form
revised 8/19/94
CLAIM NOTI¢ ~:~ ~ ~ ~~
2.000
PLEASE USE BLACK INK ONLY
(For Offic~ Use)
CLAIM ~O. O ~l.~l ,,gO00 .1
OFFIC~ .THIS. THE ~.is~ .DAY OF
rrv sEc . r v
City Secretary
City of CoppeH
PO Box 478
Coppell TX 75019
This is my notice of claim against the City of Coppell.
follows:
The injury or damage occurred on the~Y/
at approximately ~_~ o"clock
The circumstances giving rise to this claim are as
· at the specific location of.
, in Coppell, Texas.
o
The ~ or injury occurred in the.following manner:
The ~fl e~ent of my d~ ~or ~jufies ~e ~ ~flows ~ sp~ - ~a~h ~t~ b~
The amount of damages claimed is S /Z ~" t~,~
(Please Print)
Claimant r--:'uJ//' J~/i/':~-
P hone (~) ~ ) 7~
I do swear t/~_ ove ~ ~
Signed. ~'~~~ ,>~-~J~/ (~____. Date
NOTE: Article 11, 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 c~sse of death, within forty-five
(45) days of the date of death. The failure to so notify the City within the thne 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.
ANDY'S SPRINKLER SERVICE, iNC.
2420 TARPLEY RD., STE. 204
CARROLLTON, TX 75006
PHONE (972) 4t8-6998
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JOB NAM~ATtON
DESCRIPTION OF WORK D DAY WORK
~ CONTRA~
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~ ~0578
PAYMENT DUE UPON
COMPLETION OF WORK
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