Citizen Claim Form

Date

Name of applicant

Address

Telephone

Address of property damage

Date damage occurred: from

Date damage occurred: to

Nature of damage

Has the damage been repaired?

Yes

If yes, by whom?

How much was cost of repair?

Has the bill been paid?

Yes

By whom: name

When

Were you reimbursed by insurance?

Yes

If yes, how much?

When

By whom: name

Address & city

Other information