Mie CITY OF EMERYVILLE r | rt
CLAIM FORM
Please Type or Print and return to: CITY OF EMERYWILLE
City Attorney’s Office, City of Emeryville CITY CLERK'S OFFICE 1333 Park Avenue Emeryville, Ca 94608 an onOt
Phone: 510.596.4381 Fax: 510.596.3724 SEP 02 2025
Email: [email protected]
CLAIM acamer Vity of Emeryville RECEIVED
; (Name of Entity)
Claimant's name Marcie Rich a. ee
Claimant's date of birth Soa Ss
Claimant's address
Address where notices about claim are to be sent, if different from above: July 17, 2025 Date injuries, damages, or losses were Feocwercd U ly 1 Cf 2025 Adeline Street in front of 4404.
Tree branches, to be maintained by the City,
Date of incident/accident:
Location of incident/accident:
What did entity or employee do to cause this loss, damage, or injury? fell away from tree and onto Marcie Rich's vehicle (which was parked on Adeline). (Use back of this form or separate sheet if necessary to answer this question in detail.) » Not known. What are the names of the entity's employees who caused this injury, damage, or loss (if know:
Body damage to Marcie Rich's vehicle, from un-maintained What specific injuries, damages, or losses did claimant receive? tree branches having fallen upon it.
(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 coutt of jurisdiction [Government Code 910(6)]?, $544.71 insurance deductible, paid by Marcie Rich to vehicle-repair business. $500 insurance deductible, paid to auto-repair business, by Marcie Rich. How was this amount calculated (please itemize)? $44.71 not covered by insurance, paid by Marcie Rich to vehicle-rental business. (Use back of this form or separate sheet if necessary to 08/30/2025 ‘Signature:
If signed by representative:
Date Signed:
Representative’s Names Address
Telephone #
Relationship to Claimant: