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 FEB 14 2025
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST City of Emeryville RECEIVED
(Name of Entity)
Geicyler H Silva Jr
Claimant's name SS#
Claimant's date of birth _Telephone#
Claimant's address
Address where notices about chim are to be sent, it different from above: 2404 Mammoth way, Antioch CA 94531 02/10/2025
Date of incident/accident:
Date injuries, damages, or losses were discovered: 02/10/2025 Location of incident/accident: 40th st & 35th St On ramp to Hwy 24 What did entity or employee do to cause this loss, damage, or injury? Not maintain / Repair Massive potholes (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)? Damaged / cracked wheels and lost mode of transportation What specific injuries, damages, or losses did claimant receive? to and from work and also did have to pay for a tow truck to take the truck for repairs (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(t)): $9,917.01 KG1 wheels $1095 each x 4 / Sales Tax $881.01
How was this amount calculated (please itemize)?
Toyo Tires $1089 each x 4 / Labor to mount each wheel/tire $75 x 4 (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 02/13/2025 Signature:
If signed by representative:
Representative's Names. Address
Telephone #
Relationship to Claimant: