THE COMPANY RESERVES THE RIGHT TO REQUIRE NOTARIZED STATEMENT OR AFFIDAVIT (If more space is needed, please photocopy this form)
I am the owner of the property described. I did not cause or contribute to the damage set forth herein.
All statements made in this statement of claim and any attached documents are true and correct to the best of my knowledge and belief, and constitute my complete and entire claim. No material information has been withheld.