APR 2 4 2023 CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
Ciry Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
City of Emeryville
CLAIM AGAINST
(Name of Hintity)
Shaunette Monique Belle
Claimant's name SS#
Claiman's dare of birth Telephone #
Claimant's addres
Valdress where notices about claim are to be sent, if different from above:
01/12/2023
Date of incident/accident:
Dare injuries dames, or losses were discovered: 01/12/2013 40th Street, btw Harlan Street and Watts Street
Location of incident/accident:
What did entity or employee do to cause this loss, damage, or injury: Neglect to maintain/repair the city street on a highly used street.
(Use back of this form or separare sheet if necessary to answer this question in derail.) 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 Blow out to left front tire. (U'se back of this form or separate sheer 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(6P. $346.15
This is the amount paid to replace the tire.
How was this amount calculated (please itemize)?
(L'se back of this form or separate sheer if necessary to Date Signed: 04/18/2023 Signature:
If signed by representative:
Representative's Names Address
Telephone #
Relationship to Claimant: