HomeMy WebLinkAboutSabic, Mina Tort Claim JUN 25 2022, 219 Tyler St 04/04/2013 01:49 2087338812 THE MAIL ROOM PAGE 01101
II
CLAIM FOR bAMAGE OR INJURY
(NOTE: It is a requirement that this form, if us6d, 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 shzill 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 filin6 claims can be found in Title 6, Chapter 9, Idaho Code. All claims must be
filed promptly, in Writing!)
i
N
ame: Phone Number: t
Current Address: 2-1
r the Six Months Immediately Prior to the Date the Damage or Injury
Qge✓ or Injury Occurred: i
;(v Z -2-2 Time: 12:3ZA.M. or P M
Location of Occurrence: 1
Irk �p c�se—[Y,
Any Injuries? no If so, what 'iype?
Describe How! Damage or Injury Occurred:
tr' 1 e,
Au
f
1
I 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
public entity, for I '
q- CYN Vy, (damage, injury, etc.)
in the amount ofo
DATE: SIGNA URE: �'na
(You may attach any other „nformation or documentation you desire.)
'f