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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)
RAHEL NIGATE
Claimant's name SS#
Claimant's date of birth _Telephone #(
Claimant's address!
Address where norices about chim are to be sent, if different from above: 1615 Broadway, Fl 4 Oakland CA 94612 Date of incident/accident: approx January 1, 2024-present Date injuries, damages, or losses were discovered: approx January 1, 2024-present 3706 San Pablo Avenue, #319, Emeryville, California 94608 Location of incident/accident:_
When did entity or employee do to cause this loss, damage, oeinjury SOO 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 injuries, camapes, 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(0)? $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 Signert: 01/07/2025 Signature:
If signed by representative:
Andrew Wolff Address 1615 Broadway, Fl 4 Oakland CA 94612 Representative's Names
Telephone # (510) 834-3300
Relationship to Claimant: Attorney