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CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to: CITY OF EMERYVILLE
CITY CLERK'S OFFICE
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608 JAN 1 0 2025
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST CITY OF EMERYVILLE RECEIVED
(Name of Entity)
BROOK GEBRETATYOSE
Claimant's name SS#
Claimant's date of birth Telephone # (
Claimant's address
1615 Broadway, Fl 4 Oakland CA 94612
Address where notices abour claim are to be sent, if different from above:
Date of incident/accident: approx January 1, 2024-present Date injuries, damages, or losses were discovered: approx January 1, 2024-present Location of incident/accident: 3706 San Pablo Avenue, #319, Emeryville, California 94608 What did entity or employee do to cause this loss, damage, or injury» SeE attached (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)? 3706 SAN PABLO EMERYVILLE, L.P.; 3706 SAN PABLO EMERYVILLE EAH, LLC; EAH INC.; AZRA OGRESEVIC What specific injurics, damages, or losses did claimant receive? emotional distress, damage to personal property, over-payment of rent, loss of use and enjoyment, out-of-pocket expenses, see attached (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(D)? $400,000
How was this amount calculated (please itemize)?
See attached
(Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 01/07/2025 Signature:
If signed by representative:
Representative's Names Andrew Wolff Aldress 1615 Broadway, Fl 4 Oakland CA 94612 Telephone # (510) 834-3300
Relationship to Chinant: Attorney