CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to: CITY OF EMERYVILLE
CITY CLERK'S OFFICE
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608 MAR 2 7 2024
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST Emeryville Police Department RECEIVED
(Name of Entity)
Mariama Sadio
Claimant's name SS#
Claimant's date of birth _Telephone#
Claimant's address
Address where notices about claim are to be sent, if different from above: 409 13th St., 17th Floor, Oakland, CA 94612 December 28, 2023
Date of incident/accident:_
Date injuries, damages, or losses were discovered: December 28, 2023 Location of incident/accident: Intersection of Powell St. and Vallejo St., Emeryville, CA What did entity or emplovee do to cause this loss, damage, or injura Mariama Sadio was struck by an Emeryville Police Department vehicle as she was driving through the intersection. Discovery is ongoing. (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)? Juan Carlos Pardo, Emeryville Police Officer
What specific injuries, damages, or losses did claimant receive Mariama Sadio sustained significant injuries to back, chest, ribs, and anxiety. Treatment and diagnosis is ongoing. (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(f1? In excess of $35,000. Treatment and Discovery is ongoing.
How was this amount calculated (please itemize)? Past and future medical bills, lost wages in excess of $35,000. Treatment and diagnosis is ongoing.
(Use back of this form or separate sheet if necessary to answer this question in detail Date Signed:_ inarch 18,2024 Signature:
If signed by representative:
Katie Mclver 409 13th St., 17th Floor, Oakland, CA 94612 Representative's Names. Address
510-646-9616
Telephone #.
Relationship to Claimant: Attorney