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 Emeryville police department
(Name of Entity)
Claimant's name_Joseph Griffin SS#
Claimant's date of birth _Telephone #S
Claimant's address_
Address where notices about claim are to be sent, if different from above:
Date of incident/accident: 12/29/2023
Date injuries, damages, or losses were discovered:_
Location of incident/accident:_ Emergvilla. CA
What did entity or employee do to cause this loss, damage, or injury? Placed a seizure warrant on my vehicle. I informed the police department. _That my car was stolen from Oakland, CA on/or around 12/12/2023 and I got it back on 12/23/2023 (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 department...
What specific injuries, damages, or losses did claimant receive?__Impound fee. (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(f)? $3,900 How was this amount calculated (please itemize)?Tow fee Gate fee and any other charges R & R towing (El Cerrito, CA) (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 03/19/2024 Signature:
If signed by representative:
Representative's Names. Address
Telephone #.
Relationship to Claimant: