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 AUG 2 6 2024
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST City of Emeryville RECEIVED
(Name of Entity)
Jessica Burgos Fernandez
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:
08/25/24
Date of incident/accident:
08/25/24
Date injuries, damages, or losses were discovered:_
Same as above
Location of incident/accident:
tree brunches from the park located behid the parking area of the cars.
What did entity or employee do to cause this loss, damage, or injury?. (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)? different body damagesto my Testa car and he back glass broken plus the cover of the car was damaged toc 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(f)]?- not sure will put the claim though my insurance company too How was this amount calculated (please itemize)?
(Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 08/26/2024 Signature:_ Jessica Burgos
If signed by representative:
Representative's Names. Address_
Telephone #
Relationship to Claimant: