CITY OF EMERYVILLE AN
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 Entity)
Stephanie Merchant SS#
Claimant's name
Claimant's date of birth Telephone#
Claimant's address
Formica Law Group; 619 S. La Brea Ave. Los Angeles, CA 90036 Address where notices about claim are to be sent, if different from above:
01/26/2022
Date of incident/accident:
Date injuries, damages, or losses were discovered: 01/26/2022 Parking Lot at 950 40th Street; Emeryville, CA 94608
Location of incident/accident:
What did entity or employee do to cause this loss, damage, orinjury? This entity maintained an uneven pavement in its parking lot of the subject incident that caused Claimant's fall and subsequent injuries. (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)?.
What specific injuries, damages, or losses did chimant receive? Left wrist fracture with severe pain, neck pain, right knee pain, left arm pain. Presently still has hand and knee pain (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))? This case exceeds $25,000 and will be filed as an unlimited civil case.
How was this amount calculated (please itemize) Plaintiff's past and future medical expenses exceed $25,000. (Use back of this form or separate sheet if necessary to answer Date Signed: 07/18/22 Signature:
If signed by representative:
Representative's Names Stefano Formica 619 S. La Brea Ave. Los Angeles, CA 90036 _Address.
Telephone # (323) 272-3334
Relationship to Claimant: Attorney