Claim Against the City of Oakland

CLAIM AGAINST THE CITY OF OAKLAND

Please return the completed form to the Office of the City Attorney, One Frank H. Ogawa Plaza, 6th Floor, Oakland, CA 94612. Additional sheets may be attached as necessary. Enclose a postage paid envelope if you require a filing receipt.

1) CLAIMANT'S NAME:

2) ADDRESS: City: State: Zip:

HOME #: DRIVER'S LICENSE:

WORK #: SOCIAL SECURITY#:

CELL#: DATE OF BIRTH:

OCCUPATION:

AUTO INSURANCE NAME AND POLICY # (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, WOULD THE CLAIM BE A LIMITED CIVIL CASE (Less than $25,000)?

Yes No Unsure

4) ADDRESS TO WHICH NOTICES ARE TO BE SENT, IF DIFFERENT FROM LINES 1 & 2:

NAME:

ADDRESS: City: State: Zip:

PHONE#

5) DATE OF INCIDENT: TIME OF INCIDENT:

SPECIFIC LOCATION OF INCIDENT* (Address):

6) DESCRIBE THE INCIDENT INCLUDING YOUR REASON FOR BELIEVING THE CITY IS LIABLE FOR YOUR DAMAGES:

7) DESCRIBE ALL DAMAGES WHICH YOU BELIEVE YOU HAVE INCURRED AS A RESULT OF THE INCIDENT:

8) NAME(S) OF PUBLIC EMPLOYEE(S) CAUSING THE DAMAGES YOU ARE CLAIMING:

9) WERE PARAMEDICS CALLED? Yes No

10) IF YOU WENT TO A DOCTOR, LIST HIS NAME, ADDRESS & TELEPHONE NUMBER:

Date of 1st Visit: Is there a police report on file?

**Complete the diagram on the back of this form showing the location of the incident**

Any person who, with the intent to defraud, presents any false or fraudulent claim may be punished by imprisonment or fine or both.

PLEASE READ CAREFULLY

If claim is for injury and you are still under doctor's care, indicate that on the form and submit medical bills to date with status of your condition. If property damage is involved, submit two estimates of repairs or paid invoices to substantiate amount claimed. If the accident involved a vehicle, give the following information:

LICENSE NO.: YEAR/MAKE OF THE VEHICLE:

For all auto accident claims, place on the following diagram the names of streets, including North, East, South and West; indicate the place of the accident by an "X" and by showing house numbers or distances to street corners. If a City vehicle was involved, designate by letter "A" the location of the city vehicle when you first saw it, and by "B" the location of yourself or your vehicle at the time;

If your claim involves some other type of incident, use the diagram below to indicate the location where the incident occurred, showing addresses, landmarks or a photograph if necessary depicting the exact site. Failure to complete the diagram or provide a photo of the site may result in delays in the acceptance of your claim as sufficient according to CA Government Code §§ 900 et seq.

DIAGRAM / INCIDENT LOCATION NOTES: