CITY OF EMERYVILLE DEC 22 REC'D
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
LaCE DEBRADEN,
CME O JOHNO
DUNNE. INGE
Claimant's name"
Claimant's dare of birth Telephone t
Claimant's address
Address where notices about claim no to be sent, if different from above:
Dren inciden acter. Ju lY 23, 2022
sus dress 7231230/15/27/00668..
Location of incident/accident:
What did entity or enaployee do to c Ruse this as an in OES TRUE ZEN OF JUSTaCE, ate shet if necessari to answer this question in decil.)g (Use back of this form or separate sheet if necessary to answer this question in detail) Whar mount of money is claimant sceking, or which is the appropriate court of jurisdigion (Gofernment Code 910(t)P.
TENDAN
*olense irchi
low was this amount
Dare Signet: 10/ 27/22
If signed be representative:
Representative's Names, Address
Telephone #
Relationship to Claiman:_
→ 112 URA TAR) ( SE GORE INTARIMENS