Jul 25, 2024 18:28 (UTC-07) From: WWW.FAX.PLUS (Georgr Morin) To: +15105963724 El 1 of 9
CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avcnuc Emcryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINSY Emeryville Public Works
(Name of Entity)
Claimane's name George Morin
SSH
Claimant's date of birth Telephone #
Claimant's address
Address where notices about claim are to be sent, if different from above:
Date of incident/accident:_ Thursday, July 25, 2024
Date injuries, damages, or losses were discovered: Thursday, July 25, 2024 1475 Powell Street, Emeryville, CA, 94608
Location of incident/accident:_
What dict entity or employee do to cause this loss, damage, or injury? Cutthrough my cars froni bumper while perlorming work near my parked car.
Cut through my car's front bumper while performing work near my parked car. (Lise back of this form or separate sheet if necessary to answer this question in detail.) What are the names of the entity's employces who causcd this injury, damage, or loss (if known) To be determined by surveilance footage.
To be determined by surveillance footage.
What specific injuries, damages, or losses did claimant recive? Just damaged to my parked vehicle. (Use back of this form or separate sheet if necessary to answer this question in detail) What amount of money is chimant seeking, or which is the appropriate court of jurisdiction (Government Code 910(f).
Replacement of my cut/damage bumper.
How was this amount calculated (please itemize) Dollar amount to be calculated at time of repair. (Usc back of this form or separate sheet if necessary to answer this question in detail) • Digitally signed by George Morin
Date Signct: 07/25/2024 George Morin Date: 2024.07.25 18:10:15 - 0700 Signature:
If signed by representative:
Representative's Names. Address.
Telephone #
Relationship to Claimant: