Mie CITY OF EMERYVILLE ri as
CLAIM FORM
Please Type or Print and return to:
° CITY OF EMERYVILLE
City Attorney’s Office, City of Emeryville CITY CLERK'S OFFICE 1333 Park Avenue Emeryville, Ca 94608 Phone: 510.596.4381 Fax: 510.596.3724 SEP 26 2025 Email: [email protected]
CLAIM AGAINST once nie RECEIVED (Name of Entity)
Claimant's name Cielo han da Smiles SS#
Claimant's date of birth Telephone #
Claimant's address
Address where notices about claim are to be sent, if different from above:
Date of incien/accdent. yguh 2024 - present _Coouthple incidents ‘ Date injuries, damages, or losses were discovered:
Location of incdent/accident._W\ alee lecdiocs cme across ciky What did entity or employee do to cause this loss, damage, or injury? Fe ali akory Surv e:\lance [ ox \ Dickress
(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 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)]? “Yo be proven A trial -
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: Al 22] 20 2D Signature:
If signed by representative:
Representative’s Names Address
Telephone #
Relationship to Claimant: