CLAIM FORM – City Of Florence

CITY OF FLORENCE, ALABAMA
CLAIM FORM
PLEASE TYPE OR PRINT CLEARLY

NAME OF CLAIMANT:

ADDRESS OF CLAIMANT:

CLAIMANT'S DAYTIME PHONE NUMBER(S):

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DATE OF INCIDENT:

CITY DEPARTMENT INVOLVED:

LOCATION OF INCIDENT:

DESCRIPTION OF INCIDENT:

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ESTIMATED DOLLAR AMOUNT OF LOSS (IF KNOWN):

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SIGNATURE OF CLAIMANT

DATE

P. O. Box 98
FLORENCE, AL 35631-0098

Welcome to Florence, Alabama