HomeMy WebLinkAbout03) Leman Morris
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REQUEST FOR REIMBURSEMENT
FOR SEWER RELATED DAMAGES
Name of Property Owner: !-~/f1d.-A ;vi orr/ ~
Address: /S6:3 tltArb/e.. Ave.- :rcrr:Cr;5.b"'v/;(~ fA! t/7/3.CJ
~aYTelephone: F! /2.-Zlt7..-7tJS;S- Other Telephone: :Jo 2-70 <g-- "'fS'.r<t
Date of Loss: /0 - & -() (j;
.
Description of Damage: ~~+-hrooV\. V6--~;:1-
D6~ tJ~+~r 1)6--MCu::je
Costs of Repairs: $ 3 z..1, (.p z-.
Have you made a claim with your insurance?
Yes
~-
If so, has your insurance paid?
Yes
No
If so, please state amount your insurance paid: $
Do you have photographs of the damages? ~es
No
If so, please attach the photographs.
Please attach an itemized list orall expenses related to the cost of repairing the damage
that you believes was caused by the City's sewer system. Also, please attach copies of all
receipts evidencing the payment of those expenses.
~~0VL/ )Y(~)
Signature .
/0- Z 3 -() tJ:;
bate
Please submit this form along with any other supporting documentation to the
Jeffersonville Sanitary Sewer Board through the City Sewer Treatment Facility.
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THE HOME DEPOT 2002
toOO E. HWY. 131
CLARKSVILLE,IN 47129' (812)282-0470
2002 00003 06860 10107/06
SALE 61 VAS167 12:47 PM
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591534 CARPET
19.33 @ 7.92
RSN: 2 NEW AMT 4.66 MKDN
094803018164 VANITY
070798180710 AL PL CLR
D78864043013 WAX RING
2 @ 4.96
078864430103 PUTTY
008033012915 31X19 V TOP
SUBTOTAL
SALES lAX
TOTAL
CASH
CHANGE DUE
}J~'IJIIOOJ~~~I~~JI~
153.09
-63.02
149.00
1.98
9.92
0.99
59.00
310.96
18.66
$329.62
330.00
0.38
FAMILY BY DAY, FRIGHT BY NIGHT
SIX FLAGS FRIGHT FEST
GET YOUR DISCOUNTS AT WWW.SIXFLAGS.COM
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Usel~ ID:
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