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 MAY 2 2 2025
Phone: 510.596.4381 Fax: 510.596.3724
Email: [email protected]
CLAIM AGAINSTCITY OF EMERYVILLE RECEIVED
(Name of Entity)
Claimant's namePE HONE TAY SS#
Claimant's date of birth Telephone #
Claimant's addres
Address where notices about claim are to be sent, if different from above: 1835 Libretto ct, San Jose, CA 95131 Date of incident/accident: 05/10/2025 2:00 PM
Date injuries, damages, or losses were discovered: 05/10/2025 3:00 PM Location of incident/accident: 4300 Adeline St, Emeryville, CA 94608 What did entity or employee do to cause this loss, damage, or injury Emeryville PD #2505-0094 With my permission, police officers were compelled to force entry into my home after the intrude use back or des orm or ye parate Shade ecessary to insiver this question in detail.) What are the names of the entity's employees who caused this injury, damage, or loss (if known)? Emeryville Police Department officers. Police officers were very nice and they did the best for my case
What specific injuries, damages, or losses did claimant receive Damaged front main door, bathroom door and shower sliding door glass panels.
(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)]?. $2370
How was this amount calculated (please itemize) Main entry door $800, Bathroom Door $170 Shower glass panels $400 and labor $1000. Total $2370
(Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 05/22/2025 Signature: Retone Tay
If signed by representative:
Representative's Names. Address
Telephone #
Relationship to Claimant:_