PLEASE READ THE FOLLOWING CAREFULLY
For all accident claims, provide a diagram with the names of streets, including North, East, South and West; indicate place of accident by “X” and by showing house numbers or distance to street corners.
If City vehicle was involved, designate by letter “A” location of City vehicle when you first saw it, and by “B” location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at the time of accident by “A-1” and location of yourself or your vehicle at the time of the accident by “B-1” and the point of impact by “X”.
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF: AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HERE STATED UPON MY INFORMATION AND BELIEF: AND AS TO THOSE MATTERS I BELIEVE IT TO BE TRUE. I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.