PROPERTY  CLAIM NOTIFICATION FORM

John Henry Doe
c/o 123 Main Street
Anytown, [12345]
Texas

Demand & Claim against; CREDITOR NAME HERE

1.	LOSS DETAILS:

a)  Date of incident: ____________________    Time: __________________			
b)	Exact location    
of incident. 	____________________________________________________

c)	Estimate of claim 
amount and
damage.		$________________________

d)	Cause of loss.      
How did the
incident occur?	_____________________________________________________

____________________________________________________________________

2.	This section involves Theft, Attempted Theft, Damage by Theft or Vandalism/Malicious Damage.

a)	Was the property stolen?			Yes/No 	
If “No”, what evidence is there that
a theft has actually occurred?

b)	Please state to which Police		________________________________
Station you reported the loss.		
Include Crime Reference and		________________________________
name(s) of officer(s).			

Has any action been taken by		Yes/No		
the Police? If “Yes”, please give
details

c)	Item of Loss: (NOTE DESCRIPTION HERE)

d)	Was any demands made to return		Yes/No
       the property?	
	
e)	Who was the demand made to?		_____________________________

f)	Has any state agencies been contacted?	Yes/No

g)	What state agencies were contacted?	_____________________________

h)	Has any federal regulators or 
      enforcement divisions been contacted?	Yes/No

i)	Federal agencies contacted? 		_____________________________

j)	Has the insurance company for 		Yes/No
      CREDITOR NAME HERE been contacted?

k)	Has the insurance company responded?	Yes/No

l)	Insurance company’s response,
include any facts and evidence.		_____________________________

Please Print Name: John Henry Doe    

Signed: ……………………………………..      		Date: November 13, 2003

Please include additional information as available;