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CITY OF EMERYVILLE CITY OF EMERYVILLE
CITY CLERK'S OFFICE
CLAIM FORM
FEB 2 7 2024 Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
RECEIVED Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST EMERYVILLE POLICE DEPT(ARIEL RAINE)
(Name of Entity)
Claimant's name ROBERT SNELL SS#
Claimant's date of birth Telephone
Claimant's address
Address where notices about claim are to be sent, if different from above: PO bOX 2122 brentwood 9451 Date of incident/accident: 02/13/24
Date injuries, damages, or losses were discovered: 02/13/24 Location of incident/accident: HWY 24 SEE CHP REPORT 9320-2024-00554 What did entity or employee do to cause this loss, damage, or injury. UN SAFE LANE CHANGE HITTI
RIGHT REAR OF MY VEHICLE SEE REPORT
(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)?
ARIEL RAINE
What specife injurics, damages, or loses did climant receive? $3550.24 IN DAMAGE TO CAR
SEE CASEY AUTO BODY ESTIMATE
(Use back of this form or separate sheet if necessity 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)?_ $3550.24
How was this amount calculated (please itemize): CASEY ANTO BODY ESTIMATE Use back of this form or separate sheet if neces: swer this question in detail) Date Signed: 02/27124 Signature:
If signed by representative:
Representative's Names. Address
Telephone #.
Relationship to Claimant: