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Claim Form

  1. This is a filing of a claim against the City of Burlington, Iowa. You should complete this report in full and the written report constitutes your claim against the City of Burlington, Iowa. You are advised that no representations made by you to any employee of the City of Burlington, Iowa, is a part of this report unless in the report and that no representation made to you by any employee of the City of Burlington, Iowa, can in any way waive any of the requirements of law as to this report of your claim. You are further advised that failure to file this report within two (2) years of the date of the accident may invalidate your claim against the City of Burlington, Iowa.

  2. To: City of Burlington, Iowa

  3. You are hereby notified of the following claim made upon you by the undersigned as a result of the loss reported herein:

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  5. This field is not part of the form submission.