Full Text
157 N Broadway St Blackfoot, ID 83221 [PHONE REDACTED] Fax: [PHONE REDACTED] CLAIM FOR DAMAGE OR INJURY Name: _ _ _ _ Phone# (Home/ Cell): _ Current Address:---- - - Date of Damage or Injury Occurred: Time: A.Mor P.M. Location of Occurrence:---- - Any injuries? If so what type? _ Describe how damage or injury occurred: (NOTE: It is a requirement that this form, if used, be presented to and filed with the City Clerk or Secretary of the public entity involved. This form is being provided as a courtesy to assist 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 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 in writing). I hereby certify that I have read the above information and is it true and correct to the best of my knowledge. I hereby make a claim against: _ _ _ _ a public entity.for: _ _ in the amount of (damage, injury, etc.). DATE: SIGNATURE: _ (You may attach any other information or documentation you desire)