CITY OF EMERYVILLE CITY OF EMERYVILLE
CITY CLERK'S OFFICE CLAIMFORM (Amenced)
AUG 0 2 2024 Please Type or Print and return to:
City Attorney's Office, City of Emeryville
RECEIVED 1333 Park Avenuc Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINS City of Emeryville
(Name of Entity)
Claimant's name Grace Beans
SS#
Claimant's date of birth
Talan
Claimant's address
Address where notices about claim are to be sent, if different from above:_ Date of incident/accidenc February 3, 2024
Date injuries, damages, or losses were discovered: February 3, 2024, also see MRI Location of incident/accident: Close to bus stop at North East side of Shellmound and Christi in Emeryville, ca What did entity or employee do to cause this loss, damage, or injury? My right knee was injured due to trip and fall on unlevel embedded cement structure in/on sidewalk that was covered by graffitti (Use back of this form or separate sheet if necessary to answer this question in detail.) What are the names of the entity's eraployees who caused this injury, damage, or loss (lE known): UNKNOWN What specifc injuries, damages, or losses did claimant receive? see MRI (Use back of this form or separate sheet if necessary to answer this question in derail) gb
What amount of money is claimant seeking, or which is the appropriate court of jurisdiction (Government Code 910(f)?. TORDETEMANCO unlimited Cuil /Jurisdiction
How was chis amount calculated (please irenize) TO BE DETERMINED (Use back of chis form or separate sheet if necessary to answer chis question in detail) Date Signed:_ Quizust 1, 26:24 VOre
Signature
If signed by representative:
Representative's Names Morrison Fong Address. P.O. BQX 591596, SAN FRANCISCO, CA 94159 Telephone #_ 415 386-3698
Relationship to Chimene: Attorney
CITY OF EMERYVILLE
CITY CLERK'S OFFICE
AUG 0 7 2024
RECEIVED