CITY OF EMERYVILLE 7
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608 JUN 2 9 2023
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST City of Emeryville
(Name of Entity)
Michael Hunter
Claimant's name SS#
Claimant's date of birth _Telephone #
Claimant's address
Address where notices about claim are to be sent, if different from above:
05/13/2023
Date of incident/accident:
Date injurics, damages, or losses were discovered: $250 Tow Truck Extraction Fee 40th St. and Hollis St
Location of incident/accident:
What did entiy or employce do to cause this loss, damage, or injury? Improper installation of sewer (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, camage, or loss if known) Department of public works What specific injuries, damages, or losses did claimant receive? The car was undamaged and there were no injuries, but a tow truck was required to pull the vehicle's wheel out (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(Đ)3 $250 How was this amount calculated (please itize) $250 (one item: Receipt from Berry Bros Towing) (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 06/25/2023
Signature:
If signed by representative:
Representative's Names. Address
Telephone #
Relationship to Claimant: