HomeMy WebLinkAboutLombard, Deanna Tort Claim page 1 CLAIRA FOR DAIMAGE(NOTE: It is a r OR
equirement that this form if use INJURY
involved. This form is bein d, be presented to and filed with the clerk or secretary of the public entity
be consptroued to be an admission ofsl abil y or annacknowled ement of
g your claim. Providing this form to you is not an
admission nor shall it to
the
Political subdivision. Legal requirements for filing claims can be found in Title 6, Chapter 9, Idaho Calidity of a claim by theode. All claims must be
filed promptly, in writing!)
Name.
Current ddress:
Phone Number:-10�)35� � works
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Address for the Six Months j
Immediately Prior to the Date the Damage or Injury Occurred: ►y
Date Damage or Injury Occurred: 5 - 13 - aQ, Time: 54FA M. or P.M.
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Location of Occurrence:
Any Injuries? If so, what type?
Describe How Damage or Injury Occurred:
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1 hereby certify that I have read the above information and it is true and correct to the
best of my knowledge.
I hereby make a claim against L4 o , a
public entity, for 5 Lw ks- -..r,,� ��� Q-CANe '5 (damage, injury, etc.)
in the amount of z � •�� �.� 10 - �,c��t.icr�rc���jJ�S
DATE: 3 - a3 - a- a SIGNATURE:
(you may attach any other information or documentation you desire.)