Jk
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 CITY OF EMERYVILLE
(Name of Entity)
Claimant's name MARCUS VEGA-TATUM
SS#
Claimant's date of birth Telephone #
Claimant's address
Address where notices about claim are to be sent, if different from above:
SEPTEMBER 27, 2022
Date of incident/accident:
Date injuies, damages, or losses were discovered: SEPTEMBER 27, 2022 Iocation of incident/accident. WEST GRAND AVE BETWEEN MANDELA PARKWAY & PORTOLA ST.
THERE WAS POTHOLE RIGHT BEFORE THE RAILROAD TRACKS THAT WAS NOT What did entity or employee do to cause this loss, damage, or injury? NOTICEABLE ON APPROACH. AS I CAME UP TO THE TRACKS MY VEHICLE DIPPED INTO THE POTHOLE AND THEN POPPED UP AND HIT THE TRACKS AS CROSSING (Use back of this form or separate sheet if necessary to answer this question in detail.) What are the names of the entitys employees who caused this injury, damage, ot loss (if now. N/ A
THE FRONT BUMPER OF MY VEHICLE BENEATH THE GRILL IS
What specific injuries, damages, or losses did claimant receive?
CRACKED, BENT RADIATOR ON THE BOTTOM, SIDE HEADLIGHT (FOG LIGHT) DISLODGED, AND DAMAGES LISTED ON QUOTE (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)]? How was this amount calculated (please itemize)? | TOOK MY VEHICLE TO 3 DIFFERENT BODY SHOPS FOR PRICING ON REPAIR AS REQUESTED.
(Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed:_03/08/2023 Signature:
If signed by representative:
Representative's Names LaTanya Tatum _Address 3811 Loto Ct, Stockton, CA 95206 Telephone # (209) 684-8000
Relationship to Claimant: Parent