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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 Public Works
(Name of Entity)
Claimant's name Ramon Soltero SS#.
Claimant's date of birth _Telephone #
Claimant's address.
Address where notices about claim are to be sent, if different from above:_ Date of incident/acident: 1/10/23
Date injuries, damages, or losses were discovered: 1/10/23 Location of incident/accident Shellmound St/Haven St
What did entity or employee do to cause this loss, damage, or injury. Large pothole damaged my vehicle tires, hag. (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)? n/a
What specific injuries, damages, or losses did claimant receive?. n/a
(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)]? $1014.42
How was this amount calculated (please itemize) tow - $550.00, tires - $392.74, Tire Install - $71.68 (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 01/13/23
If signed by representative:
Representative's Names. Address
Telephone #.
Relationship to Claimant:_