CITY OF EMERYVILLE
CITY CLERK'S OFFICE CITY OF EMERYVILLE *
JAN 2 2 2025 CLAIM FORM
Please Type or Print and return to:
RECEIVED City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CINCE CINCKY VILE
CLAIM AGAINST
Name of Entity
ROSARIU
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:
1/ 22/25
Date of incident/accident:
Date injuries, damages, or losses were discovered:_ 1/22/25 Location of inciden/ecide. ConnEn in oF 5300 + HellEs ST:
What did entity or employee do to cause this loss, damage, or injury? mEtal coron plate ou stuttt
(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)?_ Don't Know
DAmAGE to Bettom oF CAR.
What specific injuries, damages, or losses did claimant receive? (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(PAn was putzu a Hop ImmEDFAtELy no estImAte yet,.
How was this amount caleciated (please itemiz? NO Amunt GEt, (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed:_ 1/22/25 Signature:
If signed by representative:
Representative's Names_ Address
Telephone #
Relationship to Claimant: