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
City of Emeryville
CLAIM AGAINST
(Name of Entity)
Claimant's name Lisa Wolfe
SS#
Claimant's date of birth _Telephone#
Claimant's address 1768 Ellie Court, Benicia, CA. 94510 Same
Address where notices about claim are to be sent, if different from above:
11/24/2023
Date of incident/accident:_
Date injuries, damages, or losses were discovered: 11/24/2023 @1:45 p.m. sidewalk between 1310 and 1320 East 65th St.
Location of incident/accident:'
What did entity or employee do to cause this loss, damage, or injure n/s (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)? n/a - sidewalk
What specific injuries, damages, or losses did claimant receive Fractured left wrist, fractured left thumb.
Significant bruising to right breast.
(Use back of this form or sparate 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)?. $2500
How was this amount calculated (please itemize)? Pain and Suffering, loss of use to left hand for a minimum of 2-6 weeks. Altered ability to do daily home and work functions as a result. (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: || 30/23
If signed by representative:
Representative's Names. Address.
Telephone #.
Relationship to Claimant:
* Please fix Sidewalk!