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CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST City of Emeryville
Name of Endity
Claimant's name Michael Addy SS# N/A
Claimant's date of birth Telephone #
Claimant's address
Address where notices about chim are to be sent, it different from above: 34.35 Wilshure Blud*1800 3/3|2022 Los Angeles, CA 90010
Date of incident/accident:
3/3\2022
Date injuries, damages, or losses were discovered:
Location of incident/accident: 100 47th Stamecuville CA (Parking leading to tracke felo What did entity or employee do to cause this loss, damage, orinjury? negligently and recklesslu designed and maintained and operated.
(Use back of this form or separate sheet if necessary to answer this question in detail.) What are the names of the entity's employees who caused this injury, damage, or loss (if known)?.
City i Employees
What specific injuries, damages, or losses did claimant receive tOXA patella tendon (Use back of this form or separate sheet if necessary to answer this question in detail) What amount of money is claimant seeking, or which is the appropriate court of jurisdiction [Government Code 910(f))?.
Believe to exceed #1,000,000
How was this amount calculated (please itemize)?
(Use back of this form or separate sheet if necessary to answer his quegigh in detail) Date Signed: 4/01/2022 Signature:
If signed by representative:
Representative's Names Raymond G hermezan.. 3435 listshire Blud #1800 Telephone # 323-900-5800 Los Angeles, CA 90010
Relationship to Claimant: Atorney for Claimant-michael Addy