| INSTRUCTIONS:
Do not discard any damaged items. They must be
available for inspection.
Number each piece and include the following information:
Include inventory number of item if
available
Indicate all item(s) damaged
or lost: sofa, table etc.
Describe item: constructed
material, color, pattern, serial number, model, manufacturer, original price,
Indicate type of CLAIM for each:
LOST or DAMAGED
If your claim is for damage indicate
location of damage on piece: scratch on bottom-front, chip on top-right.
If available:
Indicate estimated cost of repair:
Indicating repair company name, quote number and phone number of indicated company.
READ CAREFULLY BEFORE SUBMITTING CLAIM
I do solemnly declare by filling in this
form all claims and statements are to the best of my knowledge and believe true in every
particular way. I make this solemn declaration conscientiously believing it to be
true and knowing it of the same force and effect as if made under oath and by virtue of
" THE CANADIAN EVIDENCE ACT"
THE ABOVE CONSTITUTES MY COMPLETE AND
ENTIRE CLAIM
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