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. � � <br /> SUPPLEMENTAL CLAIMS INFORMATION SHEET <br /> This sheet is to be completed by appticant who has been involved in any claim or suit during <br /> the past i'ive (5) years or who is aware of any incidents which may give rise to a ctaim. <br /> Complete separate sheet for each ctaim or incident <br /> Answer all questions fully. <br /> Principal of firm must sign this shest in addition to the application. <br /> 1. Name of �irm: City of Deca�r <br /> �" �"� � 2 Name of Individuais of Firm Involved in Claim: Civii Service Commission <br /> 3. Name of Ctaiman� Larry Young <br /> 4. Date of Alleged ERor: 3•8-87 <br /> ' S. Date C1aim Made: 3•25-87 <br /> 8. Name of Insurer (if appii�able): <br /> 7. Preseni Status of Ciaim: p Pending ❑ Closed ❑ In Suit <br /> 8. it Ctosed. Tota! Loss Paid: <br />� Total Expenses Paid: -0- <br /> 9. ff Pendiny, Amount Asked in Summons: -0- <br /> . � <br /> Claimant s Settiement Demand: Wants job back <br /> Defe�dent's Settlement Offer: -0- <br /> insurer's Loss Resenre: -0- <br /> Expenses Paid to Date: -0- <br /> 10.Detailed description of claim and events: <br /> M�. Young is claiming race disc�imination because he was dismissed for selling drugs. <br /> Mr�'^f• <br />