CITY OF EMERYVILLE
CLAIM FORM
AUG 0 8 2024 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 City of Emeryville Public Works
Name of Entity)
Claimant's name Dorothy Mccarter SS#
Claimant's date of birth Telephone #
Claimant's addressl
Mila Afshar - 633 W 5th St #2200, Los Angeles, CA 90071 Address where notices about claim are to be sent, if different from above:
5/24/2024
Date of incident/accident:
5/24/2024
Date injuries, damages, or losses were discovered:
Sidewalk in front of Claimant's address 4001 Adeline St Emeryville, California 94608 Location of incident/accident:
The city falad to reascnably inspect, maintain, and repair the side walk. There was a metal grate on the sidewalk What did entity or employee do to cause this loss, damage, or injury? that was raised and i was not aligned with the rest of the sidewalk, creating a dangerous condition in the form of a tripping hazard. Claimant tripped on the dangerous condition and fell, sustaining serious injuries. (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)?.
Unknown at this time
What specific injuries, damages, or losses did claimant receive? Injuries: Dislocated and broken left ankle
(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]. $5,000,000
How was this amount calculated (please itemize)?
(Use back of this form or separate sheet if necessary to answer this question in detail) Date siened: 08/07/2024 fishar.
Signature:
If signed by representative:
Mila Afshar 633 W 5th St #2200, Los Angeles, CA 90071
Representative's Names, Address
Telephone # 213) 757-6029
Relationship to Claimane: Legal Representative