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): *

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 *

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DATE *

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

Enter the Correct Answer *

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