CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryvile
1333 Park Avenuc Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINS: Emeryville police Pepartment
(Name of Entity)
SS#
Claimant's name DevIn Bosley
_Telephone #S
Claimant's date of birth
Claimant's addres:
Address where notices about claim are to be sent, if different from above:, Dato incideal acident 12 13/21 (arrest of Anthony Boyd
Date injuries, damages, or losses were discovered: 12 15/21 Location of inciden accident. Da Kland, CA
What did entiy or employce do to us this los damage, origing wrong fully searched vehicle the keys.
after Devin asked for (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 knows?_ arrestins officer" name unknern
What specific injuries, damages, or losses did claimant receive Wrongful towins, butant vehicle release
(Use back of this form or separate sheet if necessary to answer this question in detail What amount of money is claimant secking, or which is the appropriate court of jurisdiction (Government Code 910(0)?. $1, 246, also a $439.99 Ruger 1c9S (SN: 458-1157) is beins withheld
How was this amount calculated (please imize) Veceipts ave Itemized (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: Le / 4 | 22 Signatur
If signed by represcatative:
Representative's Names Address
Telephone #
Relationship to Claimant: