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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
CLAIM AGAINST City of Emeryville and Emeryville Police Department Employees (Name of Entity)
Claimant's name Jonathan Peterson
SSH
Claimant's date of birth Telephone #
2121 Natomas Crossing Drive, Suite 200-389, Sacramento CA 95834 Claimant's address
Address where notices about claim are to be sent, if different from above:
Date of incident/accident: July 24, 2023
Date injuries, damages, or losses were discovered: uly 24, 2023 Location of incident/accident: 1800 Powell Street, Emeryville, CA See Attached
What did entity or employee do to cause this loss, damage, or injury? (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) Emeryville Police Officers Berrian #377 and Selby #388, and Sergeant Pardo #365 See Attached
What specific injuries, damages, or losses did claimant receive? (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(D]? In excess of $50,000.00 Unlimited Jurisdiction Alameda County Superior Court or Northern District of California How was this amount calculated (please itemize)?
(Use back of this form or separate sheet if necessary to answer this question in detail) 1-8-2024
Date Signed:_ Signature:
If signed by representative:
Representative's Names Justin L. Ward 2121 Natomas Crossing Drive, Suite 200-389, Sacramento, CA 95834 Address
Telephone # 916-443-2474
Relationship to Claimant: Attorney