Claim Notice CLAIM NOTICE (For Office Use Only)
CLAIM NO. FILED IN
MY OFFICE THIS THE DAY OF
, 20
ADMINISTRATIVE SECRETARY
City Secretary
City of Coppell (972) 304 -3673 (FAX)
P.O. Box 9478
Coppell, TX 75019
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 , 20 , at
approximately o'clock , at the specific location of
, in Coppell, Texas.
2. The damage or injury occurred in the following manner:
3. The full extent of my damages and /or injuries are as follows (be specific - attach estimates,
bills, etc. if available):
4. The amount of damages claimed is $
(Please Print)
Claimant Phone ( )
Area Code
Address City /State /Zip
(Also list previous address if less than 6 months)
* * * * * * * * * * * * * * * * * * * * * * * * * * * * **
I do swear the above is true and correct.
Signed Date
The notification shall be filed within six (6) months of the date of injury or damage or, in the case of death, within six (6) months 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. (Article 11, Section 11.09 of the Home Rule Charter - Damage Suits)
Revised 06/03/02