HomeMy WebLinkAbout2021 Lia Barnhart 195 Tyler St Tort Claim CLAIMFOR DAMAGE OR INJURY
(NOTE: It is a requirement that this form, if used, be presented to and filed with the clerk or secretary of the public entity
involved. This form is being provided as a courtesy to assist you in filing your claim. Providing this form to you is not an
admission nor shall it be construed to be an admission of liability or an acknowledgement of the validity of a claim by the
political subdivision. Legal requirements for filing claims can be found in Title 6, Chapter 9, Idaho Code. All claims must be
filed promptly, in writing!)
Name: cA Ba rt' VAa r� Phone Number: (Home(R,5� 10 _S346,0
Current Address: L. .� ,j {- ( �, :�_ { 5 t LTD S" � j
Address for the Six Months Immediately Prior to the Date the Damage or Injury
Occurred: { {er ( Is c TtD 33 ,3 () )
Date Damage or Injury Occurred: �� 4(b)[ i�ne: A.M. or P.M k '` d c"`� I�
Location of Occurrence: + Lu � tA � ;
Any Injuries? If so, what type?
Describe How Damage or Injury Occurred:
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I hereby certify that I have read the above information and it is true and correct to the
best of my knowledge.
hereby make a claim against t d T W i n S coask nq a V,0,%C (T+
public entity, for rr�G -e-, 5W 0 Y V_ C.- (damage, injury, etc.)
in the amount of > T v-\ k i- j
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DATE: i 1 AQ i SIGNATURE:
(You may attach any other infor atio, or 4"ntation you desire.)