CITY OF EMERYVILLE
CLAIM FORM
Plcase Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
Phonc: 510.596.4380 Fax: 510.596.3724
CLAIM AGANST LewiS Dwain LonNaY
Name of Entity-
Claimant's name_ Le
Thi Duong SS#
Claimant's date of birth Telephone #
Claimant's address
Address where notices about claim are to be sent, if different from above:
Dac o incident/cident: 9/29/22
Date igurie, damages, or asses wer discovered: 9/29/22
Location of incident/accident: Christie Ave
What did entity or employce do to cause this loss, damage, or injury? Please See Police report attached
(Use back of this form or separate sheet if necessary to answer this question in detail.) What are the names of the entity's employces who caused this injury, damage, or loss (if known)? What specific injuries, damages, or losses did claimant reccive? back bumper damage Please See a Hacked Phots
(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(t)P- $193/ (158051 1 350 car rental )
How was this amount calculated (please itemize)? 1580.53 fur the bumper placemen takes ~ a Neck to finish pub, car nill be in ship. I nill need (Use back of this form or separate sheet if necessary to answer this question in detail a pental 50 050 a day fur 7 das
Da Spank: 12/8/22 Signature S0 $350
If signed by representative: (car rent)
Representative's Names Address
Telephone #
Relationship to Claimant: