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NOTE If diagrams below do not fit the situation attach hereto a proper diagram signed by claimant. I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. DATE PLACE CLAIMANT S SIGNATURE PRINTED NAME. E. NAME TELEPHONE NUMBER AND ADDRESS TO WHICH CLAIMANT DESIRES NOTICES TO BE SENT IF OTHER THAN ABOVE OCCURRENCE OR EVENT FROM WHICH CLAIM ARISES a. DATE b. Claimant is advised to consult a private attorney if legal advice is desired. No employee of...
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