1

Name:

 *

Name:

First Name:

Last Name:

2

Address:

 *

Address:

Street:

City:

Zip:

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3

Phone:

 *

Phone:

Main:

Work:

Email Address:

4

Incident:

 *

Incident:

Date of Incident:

Time of Day:

Location:

5

Claim:

 *

Total Amount of Claim ( must be a whole number):

6

Please Provide Two Estimates (You must upload files separately)

 *

Please Provide Two Estimates (You must upload files separately)

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7

Pictures or Drawings:

Pictures or Drawings:

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8

Describe in your own words where, when, and how the damage or injury occurred. Attach additional pages if necessary. Give names and addresses of others involved. Attach copies of any repair bills, estimates, medical bills, etc. Claim must be filed within six months of injury or property damage:

Describe in your own words where, when, and how the damage or injury occurred. Attach additional pages if necessary. Give names and addresses of others involved. Attach copies of any repair bills, estimates, medical bills, etc. Claim must be filed within six months of injury or property damage:

CITY OF RICHARDSON CHARTER ARTICLE SECTION 17.02.

NOTICE OF DAMAGE OR INJURY

The City of Richardson shall never be liable for any personal injury, whether resulting in death or not, or for damage to real or personal property unless the person who is injured or whose property is damaged or someone in such person's behalf, or in the event the injury results in death, the person or persons who may have a cause of action under the law by reason of such death injury, shall file a notice in writing with the city manager or city secretary within six (6) months after the day that the incident giving rise to the claim for damage or injury occurred, stating specifically in such notice when, where and how the exact injury, death or property damage occurred and the full extent thereof, together with the amount of damages claimed or asserted. Provided, however, nothing herein contained shall be construed to mean that the city waives any rights, privileges, defenses or immunities which are provided under the common law, the Constitution and laws of the State of Texas.

State Law

Under State law the city is not liable for any claim unless proper and timely notice of claim is filed with the city; and is not liable for property damages and personal injuries caused in the performance of a governmental function. The liability of the city for property damage and personal liability is limited by the Texas Tort Claims Act and other applicable law. The city is not responsible or liable for damages or injuries caused by independent contractors. The city is not responsible or liable for property damage caused by a defect in a road, alley or on city property unless the city was aware of such condition at the time of the incident and failed to warn the public of such condition. The city is not responsible or liable for property damage or personal injury arising from the use of a motor driven vehicle or motor driven equipment unless caused by the negligent use of a motor driven vehicle or motor driven equipment by a city employee acting within the scope of employment. The city is not responsible or liable for personal injury arising from a condition or use of personal or real property unless caused by the negligence of a city employee acting within the scope of employment.

9

I have read "City of Richardson Charter - Article 17.02" above and certify by submittal of this form that all of the statements made in this claim are true and correct to the best of my knowledge.

Yes

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