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. .. � ► <br /> SUPPLEMENTAL CLAIMS tNFORMATION SHE� <br /> This sheei is to be completed by applicant who has been involved in any claim or suit during <br /> the past five (5) years or who is aware of any incidents which may give rise to a ctaim. <br /> Complete separate sheet for each claim or incident <br /> Answer aii questions fully. <br /> Principai of firm must sign this sfieei in addition to the appiication. <br /> 1. Name of F��m: City of Decatur <br />� - ��� � Z Name of lndividuals of Firm invoived in C1aim: Civil Service Commissian <br /> 3. Name of Claiman� larry Young <br /> 4. Date of Alleged Erro� 3-8-87 <br /> ' S. Date Claim Made: 3-25-87 <br /> 6. Name of Insurer (if applicable): <br /> 7. Present Status of Ctaim: p Pending ❑ Closed ❑ In Suit <br /> 8. if Ctosed. Totai Loss Paid: <br /> Total Expenses Paid: -Q- <br /> S. If Pending. Amount Asked in Summons: -0- <br />� C�aimanYs Setdement Demand: Wants job bacfc <br /> DefendenYs Settlement Offer: -0- <br /> tnsurer's Loss Reserve: -0- <br />' Expenses Paici to Date: -0- <br /> 10.Detailed description of ctaim and events: <br /> Mr. Young is claiming race discrimination because he was dismissed for selling drugs. <br /> n+,.r.,;^ae <br />