SEP 0 8 2023
CITY OF EMERYVILLE
$11,00 CLAIM FORM
Please Type or Print and return to:
City Attorey's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
Eneryville PD
CLAIM AGAINST-
Kevin Fran Kian 1
SS#
Claimant's nathe.
_Telephone
Claimant's date of birth
Claimant's address,
Address where notices about claim are to be sent, if different from above:- -24-23
Date ofincident/accident_
Date injuries, damages, or losses were discovered: Target 735407RF Emerve n Location of incident/accident:_
What did eptijy or employe do to cause this loss, damage, or injury I legg search - + Property-talse Report-eaceve (Use back of this form or separate sheet if necessary to 344
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What specifig injuries, damages, or losses did claimant receive?. = pain - numnes (Use back of this form or separate sheet if necessary to answer this question in detail What amount of moneyis claimant seeking, or which is the appropriate court of jurisdiction Government Code 910(g). - 457.30 How me this amous claired (le remin. Audi Dealer 8-23-23
Date Signed: L
If signed by representative:
Address_
Representative's Names,
Telephone #
Relationship to Claimant.