Deed SMIABLE FOR YOUR DAMAGES: Ci t'S Dect oy Minding Hin, at a4 Dept ; An. Ce Cag WO 04 9 UE CLAIM AGAINST TH.. CITY OF OAKLAND Please return the completed form to the Office of the City Attorney, One Prank H. Ogawa Plaza, 6th Floor, Oakland, CA 94612, Additional sheets ‘may be attached as ne Enclose a postage paid envelope if you require a filing receipt ECEIYED AKLEND CITY A 2 } WI2FEB23 PH 326 / (WV 1) CLAIMANT'SNAM 2) ADDRE HOME #: WORK SOCIAL SECURITY: _ CELL COVERED BY MEDICARE? ___ IF YES, MEDICARE # —_ DATE OF BIRTH: OCCUPATION: (tee AUTO INSURANCE NAME AND POLI (if applicable) 3) IF AMOUNT CLAIMED IS LESS THAN $10,000, AMOUNT OF CLAIM: $ - (Attach copies of expenses substantiating the basis of computation for the amount being claimed) IF AMOUNT CLAIMED EXCEEDS $10,000 Yes Nou WOULD THE CLAIM LIMITED CIVIL CASE (Less than $2: 4) ADDRESS TO WHICH NOTICES ARE TO BE SENT, IF DIFFERENT FROM LINES 1 & 2: NAME ADDRESS: PHONE DATE OF INCIDENT, ed TIME OF INCIDENT:__ _ ‘SPECIFIC LOCATION OF INCIDENT* (Address): Fay | Cafe) Cts 6) DESCRIBE THE INCIDENT INCLUDING YOUR REASON FOR BELIEVING THE CITY ~ ) Etstlogen Retest as CMLL, £pee4, Clr en 2 Hey bbec ius beri” py eStcAtte “Puc pod “FE Ins vo 7 ke © Remeetial Rete Whim D fave fen Sebi ceted fe Crol Teatheal La yi DESCRIBE ALL DAMAGES WHICH YOU BELIEVE YOU HAVE INCURRED ASARESULT 4o r che OF THE INCIDENT: Generel! cf ose snes RE ry Nera Opel a BSS gush, enote mel hthens enon oe ond B 4 ort fo toot fp ee 8) NAMEIS) OF PUBLIC EMPLOYEIS) CAUSING THE DAMAGES YOU ARE CLAIMING 9}. WERE PARAMSDICS CALLED? 10) IF YOU WENT TO A DOCTOR, LISTHIS NAME. cy lemanses fo le St Oye, Rpt Al KARL Date of 1" Visit, **Complete the diagram on the back of this form showing the loc Any person who, with the intent to defraud, presents any false or frauduler Claims must be filed within 6 months of the incident. of the incident=* claim may be punished by imprisonment or fine or both -e Government Code §§ 900 ct sea." (Revised 10/26/10)