DR8902-CS 881107CLAIM NOTICE (FOR OFFICE USE)
CLAIM NO. t~ ~)7 f~ F~IL~D
IN MY OFFICE, THIS THE, 19~
DAY OF/~-~~-
City Secretary, City of Coppell /~.~.~T7~CITY SECRETARY
P.O. Box 478
Coppell, TX 75019
Dear Sir:
This is my notice of claim against the City of Coppell. The
circumstances giving rise to this claim are as follows:
1. The injury or damage occurred on the ~_day of
19~ at approximately ~ o'clock ~ , at the specific location
of ?o~-- ~~' ~fOOz' /~0 in Coppell, Texas.
2. The damage or injury occurred in the following manner:
~. The full e%~en[ of my ~ges and/or injuries a~e as
follows (be specific; attach estimates, bills, etc., if available):
4. The amount of damages claimed is $ ~O~ ' ~'
(please p~int ~ ~0 $ ~ ~4~7~7~.'~ PHONE
CLAIMANT'~/~ ~7~
ADDRESS'~--~'Z~ ~'~c~_ ~O CITY/STATE ~(~t~. ~--~ 7~Z
**************************************
SI GNED .~/~ ~ DATE ~>.
NOTE:
ARTICLE 6252-19, SECTION 16,V.A.T.S. - NOTICE OF DEATH OR INJURY
"Sec. 16. NOTICE REQUIRED-Except where there is actual notice on
the part of the governmental unit that death has occurred or that
the claimant has received some injury, any person making a claim
hereunder shall give notice of the same to the governmental unit
against which such claim is made, reasonably describing the injury
claimed and the time. manner and place of the incident from which
it arose, withim forty five (45) days from the date of the incident"
QUOTATION
~ ~ C No.
' -- Date ~ -~-- ~
~ To ~ Terms & ~ / ~-
'~ ~~ ~~ ~. Conditions ~ ,
Estimated
Delive~
We are pieced to submit the following prices and specifications.
Quanti~ Description Price Amount
Quotation Prepared By I '~'-/~'~?'-' f~ £'~ '? ~..~ Total
... -~/~/~
!+ScPibbletmx~l NO. ]9125