City of Bangor

Sewer Back Up Claim Form

Notice of Claim of Sewer Back Up

          Name:                                                                                                              

      Address:                                                                                                                         

Address of

Affected Property:                                                                                                                

(If different than above)

Date of Discovery of Property

Damages or Physical Injuries:                                                                                            

Return this form:                                            An individual that has been injured or

Michael Selden, City Manager                    has suffered property damage as a

City of Bangor                                               result of a Sewage Disposal Event

257 West Monroe Street                              MUST provide written notice of the

Bangor, MI 49013                                         event within 45 days after the date the

                                                                        damage or injury was, or in exercise

                                                                        of reasonable diligence should have

                                                                        been discovered.  Failure to provide

                                                                        proper notice will bar your claim.

FOR OFFICE USE ONLY!

Date Received:                                             

Forwarded to:                                                                         Date:                                      

Forwarded to:                                                                         Date:                                      

Forwarded to:                                                                         Date: