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 Entie!)
Micheel Mironda
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:
I ocation of incident/accident: 104,3 48th st Emergrille CA 9460B. Private parkry What did entity or employee do to cause this loss, damage, or injury? Bock of form # 1
(Lise 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.
What specific injuries, damages, or losses did claimant receive? 1 2083 infiniti G35 coupe.
Vehicle. color black
(Use back of this form or separate sheet if necessary to answer this question in detail What amount of money is claimant secking, or which is the appropriate court of jurisdiction [Government Code 910(fIP. 14,315.24
How was this amount calculated (please itemize)?_
Back of forma #2
(Use back of this form or separate sheet if necessary to answer s question i a detail) Da son 09/06/24
If signed by representative:
Representative's Names. Address.
Telephone#
Relationship to Claimant:
# 1 A tree located at temescal park Had
A bronch fall and damage the right passonger
side of my vehicle.
#2-vehicle on the market
1,750.90
- Rimg 3rd party - Bucket seats
pair
$800 #324.11
- suspension, coilovers
sound system
K499 -
$1,001,23
Totol
14,375.24