CITY OF EMERYVILLE
CLAIM FORM
CITY OF EMERYVILLE
Please Type or Print and return to: CITY CLERK'S OFFICE City Attorney's Office, City of Emeryville JUN 0 5 2023 1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
RECEIVED
CLAIM AGAINST Emeryville Police Department
(Name of Entity)
Chimant's name Eric. Jones 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/accident: 5/22/23
Date injuries, damages, or losses were discovered: 5/22/23 Location of incident/accident:_ 6St st Overland Ave Emeryville CA 94608 What did entity or employe do to cause this os, drimage, ar inju?. Had my car wrongfully impounded causing me to lose the car.
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)? What specific injuries, damages, or losses did claimant receive? I lost my car (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()P. $10,000
How was this amount calculated (plense itemize)? Cost paid for car - $3,000 new transmission - $1,500 Transmission instalation - 121,100, Amnestu orggram =#1,020 → (Use back of this form or separate sheet if necessary to a Date Signed: 6/ 5/23 Signature:
If signed by representative:
Representative's Names Address
Telephone #
Relationship to Claimant:
+ $3,380 to compensate me for jeopordizing my credit score