CITY OF FAYETTEVILLE CLAIM FORM INSTRUCTIONS: Complete this form and clearly state the reason for the claim, amount you are claiming, and attach appropriate documentation including receipts or three estimates. Additional sheets may be used. Please mail to or drop by the: City Administration Bldg., Mayor’s Office, 113 W. Mountain, Fayetteville, AR 72701 (479-575-8330) Fax-479-575-8257 CLAIMANT INFORMATION: NAME: First, Middle, Last __________________________________________________________ STREET ADDRESS: __________________________________________________________ CITY, STATE & ZIP: _________________________________________________________ PHONE NO: _____________________ SOCIAL SECURITY NO: ___________________ INCIDENT INFORMATION: Address of Occurrence: ________________________________________________________ Date of Occurrence: ____________________________________________________________ Nature of Occurrence: Sewer Water Pothole Other _____________ Amount Being Claimed: ________________________________________________________ The undersigned hereby files a claim(s) against the City of Fayetteville, Arkansas for the following reason(s): ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ___________________________________________ Signature __________________________ Date ___________________________________________ Received by __________________________ Date Received ___________________________________________ Referred To __________________________ Date _________________________ DEPARTMENT DIRECTOR ______ DATE ___________ ACCEPTED ________ DENIED American LegalNet, Inc. www.USCourtForms.com