HomeMy WebLinkAbout1980 Shoup Ave E Yuridia Silver - Tort Claim Claim for Property Damage or Bodily Injury
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NOTE: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 Idaho Code:Title 6.Chapter 9.All claims must be filed promptly.
CLAIMANT INFORMATION:
First Name:* Last Name:
Yuridia Silver
Physical Address
Street*
1980 e shoup ave
City* State* ZIP Code*
Twin falls Idaho 83301
Have you lived at this address for at least 6 months prior to the incident date?
Yes No
My mailing address is different than my physical address
Phone Number* Email Address:
xxx-xxx-xxxx
INCIDENT INFORMATION:
......................................................................................................................................................................................................................................................................................................................................................................................................................... . .
Date of Incident:*
12/23/24 04:51:00 AM
Location of Incident:*
1980 e shoup ave twin falls idaho
DESCRIBE IN DETAIL WHAT DAMAGE OR INJURY OCCURRED:
List of damage items and material for the water. Twin size captains bed,mini fridge,full size refrigerator,wooden desk,2 wood night
stands,1 wooden decorative wall,50 yards of carpet,wall paint,collection of sports cards,water heater,the gravel in the driveway.List of
service 1000 to have the water pumped out,and dehumidify basement.$1500 cleaning crew.
Additional Files/Pictures:
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You may attach any other information or documentation you desire.
Cost of Property Damage or Bodily Injury:
$7,500.00
Property Damage or Bodily Injury:*
Property Damage
Bodily Injury
Property Damage and Bodily Injury
I hereby make a claim against the City of Twin Falls and I hereby certify that I have read the above information and it is true and correct to the
best of my knowledge.
Date* Signature*
12/30/2024
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Per Idaho Statute Title 41,Chapter 13:41-1331 -Any person who knowingly,and with intent to defraud or deceive any insurance company,files a
statement of claim containing any false,incomplete,or misleading information is guilty of a felony."Statement"includes,but is not limited to,
any notice,statement,proof of loss,bill of lading,receipt for payment,invoice,account,estimate of property damages,bills for services,
diagnosis,prescription,hospital or doctor records,x-ray test results,or other evidence of loss,injury,or expense.