CITY OF EMERYVILLE CITY OF EMERYVILLE
CITY CLERK'S OFFICE 75
CLAIM FORM
SEP 2 3 2024
Please Type or Print and return to:
City Attorney's Office, City of Emeryville
RECEIVED 1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST aty ef Emeryville
Name of Entity
Claimant's name Adelaide Jenkins 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:_ 1/12/2024
Date injuries, damages, or losses were discovered: 4/12/2024 - still getting costs Location of incident/accident: approx. 4080 Horton - near 4065 What did entity or employee do to cause this loss, damage, or injury?_ metal grate around tree ons mis sacer and anales up censing trip hazard.
Use back of this form or separate sheet if necessarv to answer this question in detail.) / What are the names of the entity's employees who caused this injury, damage, or loss (if known)?_ NA What specific injuries, damages, or loses did claimant receive broken e dislocated wrist ano sprunes 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(fP. $5,000.00
How was this amount calculated (please itemize)? please see attached (Use back of this form or separate sheet if necessary to answer this question in detail Date Signed:_ 9/19/24 Signature:_ i rulers.
If signed by representative:
Representative's Names. Address.
Telephone #.
Relationship to Claimant: