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
City of Emeryville
CLAIM AGAINST.
Name of Entit
Michoel Mironcon
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:
Date of incident/accident:_ 8|25/2024
8/25|2024
Date injuries, damages, or losses were discovered:
Location of incident/accident: 1043 48th st Emergrille CA 9460B. Private parkin What did entity or employee do to cause this loss, damage, or injury? Bock of form # 1
(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)? Not Applicable.
1 2003 infiniti G735 coupe.
What specific injuries, damages, or losses did claimant receive?.
Vehicle. color black
(Use back of this form or separate sheet if necessary to answer this question in detail) What amount ot moneys claimant seeking, or which is the appropriate ourt ot jurisdiction Government Code SI9()F 14,375.24
How was this amount calculated (please itemize)?
Back of forma #?
(Use back of this form or separate sheet if necessary to answer his question Das son 09/06/24
If signed by representative:
Representative's Names_ Address
Telephone #
Relationship to Claimant:_