Property Damage Claim Form - City Of Chicago Page 2
ADVERTISEMENT
1
214.
Witness City, State & Zip Code:
15.
Witness Telephone:
Office
Home
Cellular
16.
Description of Incident (give
details of how damage
occurred)* Use additional sheet
if necessary:
17.
Police Report Number:
18.
City Department Report:
19.
Two Written Itemized Estimates
attached on company
letterhead or Itemized Paid Bill
with proof of payment
Two Written Estimates ______
Itemized Paid Bill ______
attached:
20.
Additional information
submitted
(i.e. photos, etc.):
21.
I am aware of the substantial
penalties, attorneys’, and legal
fees that may be imposed for
____________________________
____________________________
filing a false or fraudulent
Signature
Date
claim, pursuant to Municipal
Code, Ch. 1, Sec. 1-22-020:
22.
Certification - This signature
certifies that the information on
this form is true and accurate to
the best of my knowledge. I
have submitted this
information in a manner that
____________________________
____________________________
represents the true facts of this
Signature
Date
claim for the purpose of
investigating this claim.
Mail this form to:
REMEMBER
Office of the City Clerk/City of Chicago
121 North LaSalle Street, Room 107
--
Respond to all questions
Chicago, Illinois 60602
--
Attach supporting evidence and information
ATTN: CLAIMS
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business