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i . <br /> • <br /> • <br /> Administrative Claim Form <br /> Name: O c S f f /v ii Address: <br /> E a0 5/ civ a o D ,12,4 A � <br /> Phone: '7 6-31(p y) 1-7631s6 (Night) /'IOUNDS V/E MAI / <br /> Date of Incident: )1 —D6 -- Location: Sou 7N SIP& of= g F L -iz,q y �ALLRoa� <br /> Witnesses: Give name, address and phone numbers: 6054-4460D <br /> / C(� ELLE 5FUeGZSo Atpm1,v sTgP7Yo^/ (26-7AR; <br /> �pt PzJTY <br /> ✓!'f o u N D S V t EL.,/ C i; MALL 2 tt c f /1 f cii Lv,c1 y 10 /1 o 6A/R5 W Ew ni.✓S`S/l Z <br /> In the space provided below, provide all details which support your claim: • <br /> 'pl REcTED A Cris-5' C/-,7 PL.oYEC Tc gliz /ilavE <br /> m CAm KA/ Sly''' Fog ciTY cavNciL ff ori 91zoP-p -7 - <br /> gFL - f AIE ALL Roo/7-7 , TNF CITY DID ®voT KEEP <br /> Jl-t� SIGAI /SND 1JM CLA //7 /r✓5- 774E Ap..7du,v pci <br /> PL A C S7/7- "✓T C si S a / 7W .5" Oj i' q JO- C—C) <br /> ASKED /W Cil ,EIALL Iso nQtrc� TFIi$ . Sf5'Ai ic'aR /77 <br /> cAl )(—o9 - IT /Ev'er2 S,.lo4-vE D U / <br /> Itemized list of expenses (attach all estimates, receipts, or list of out-of—pocket expenses): <br /> 30 x /s- .S/ �'N PC 5`-wa w D /NTEv AA/1) LE-77-6R <br /> l7 <br /> ON 2107-/-t .573E/S-. <br /> / 3E' -- 3 colo nS , <br /> Attach photos of any damage, if appropriate. <br /> 410 <br /> 2_ - C d'?be-1- -1 • <br /> • <br /> Date Claim Made Signature 61 Claimant <br /> • <br />