CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
RECEIVED
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608 AUG 0 6 2025
Phone: 510.596.4381 Fax: 510.596.3724
Email: [email protected] CITY MANAGER'S OFFICE CLAIM AGAINST City of Emeryville Public Works CITY OF EMERYVILLE (Name of Entity)
Marcia Morse
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:
.6/12/25
Date of incident/accident:
Date injuries, damages, or losses were discovered: 6/12/25 45th Street near cross street Adeline
Location of incident/accident:_
What did entity or employee do to cause this loss, damage, or injury? Failure to trim old tree (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)?.
What specific injuries, damages, or losses did chimant received Damage to my car (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]? $230.07
How was this amount calculated (please itemize) $100 auto insurance deductible + $130.07 out of pocket for rental car (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 08/05/2025 Signature Marcia Morse
If signed by representative:
Representative's Names. _Address.
Telephone #
Relationship to Claimant: