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- . 6.3B
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<br /> t I` ��1 ���IC�.. � .� 't.,.. �
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<br /> ��►�M �'ORM ��'�; -- - N ; City of Redwood City
<br /> nlease rint ar t e '�! �� ��L � � 2 0 0 7 �i�i��Q��i C i t y C�e r i<
<br /> � A yp � � � ��# Oelltnenie 1017 Nfiddlefield Raad
<br /> � c3���rr;���.^ac;�c�ct t""l t���oanaeoiasr Redwood City, CA 940G3
<br /> �-�-.�.--�,�,r'���;���',`-�-=�--- �eteprrone: �sa-�soa000
<br /> F�X: �so-2��-��a�
<br /> CLAIM AGAlNST(Name of Entity): Ci of Redwoad Ci
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<br /> Claimant's Name: � ��� �� !�/'�'j , , .. ,.. DOB: ��, �
<br /> Ciaimant's Address: �.��_�_ �L �,�1�"'�{1��i`.J �/'"�,' i ( .,!�Y7��;�_�li ,������ �/i�✓ CF n��
<br /> ��-�(7 i `^ � � �- ��`.
<br /> Claimant'sTel�phoneNumber� jHome� �I ���� (Wo�l<j J�i??��
<br /> Address U�h�re notires about c{aim,are to be sert, if diffe;ent from�bove: _ �.-�1� �rG�'�l G'� �,�,�,� `y>'��1�
<br /> '��.� /;J���- �Ul3r�✓'✓l�.et �j%�?/� �iJh.� ,�/�✓✓ /2/�C7��0 C,�GI� /��'f�i7Z
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<br /> Date of incident/accident: / � /
<br /> D�te injuries, d�mages,or losses were discovered: �/l �� /
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<br /> Location af incident or accicfent: ����'�JC� /i�' �' �;�� . '� �i%j��
<br /> Wh�t did entity or empioyee do to cause Ti�is i»jury,damage,or lass: L�i�G�:.%rL'i•�?�-�.. I�i` ��J U ���'/���
<br /> f rr71$�tS)
<br /> _____��� /���; /'�'. C�"fJiy�;'�;� _. ��J:i�� 1�1d�-,�rl�S ) �'ap�''J� `.�-'�J'��°�''a�vr�m.�',�,�I7 i�'���,�.�% '
<br /> / tUse back of this form or a separate sheet if necess�ry to answ'er this question ir detaii.; �' y
<br /> ,Ti,i,✓,�s;��
<br /> Wh�t�re the names of ihe entity's emplayees who caused th�s injury,d�m�ge, or foss(if I<nown�: r✓'��L-- �N�'"'`�'"q'
<br /> ,(� ��/ > G.�i �rwYp�_�:57
<br /> — �''`�``',��'- ; J ci'�' �-�; �/v�''/ r %';''��T;L,�v' . � `t'"/�? ' � i'n �'` ;�� �
<br /> ?/ j � ,rlr�r° /�C^i�' � �����s� �•4�L��'�
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<br /> What specific injuries, damages,or losses did�(aimartt receive? >G•�'!'���'- ��v� �%¢^���'c-G�''•'*'�- .F?���'��lG�<<,
<br /> �iv .���. �" ���-�'�?T ���G"y�-�'�;"r , ,/7./�(:� , ,�%�'%' ,1',�'+1'`�.� .;/; � ,�
<br /> f Use back of this form or a sep�rate sheet if necessary to�nswer thrs que tion ih detail.J
<br /> What amount of money is claimant seel<ing,or if amount is in excess of$10,000, whirh is the appropriate Court of
<br /> Jurisdiction. Nate: if Superior�nd Municipat Courts are consolidated,you musC represent whether it is a"fimited
<br /> civi!case" �see G�vernment Code 910[i]j.
<br /> �/��'l��7���;Q v"t//�,S;�)C i 7 c�� ,U ,SL c���, I�3�
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<br /> How was this amount cafcuiated Zplease itemizeJ: �t , ��%�r, t� �V' �' —�l�--�' �7��,� ,,����%���:�
<br /> - ' +I�L_� �,'..ro �,,�ft,i �+/Gs;✓r/����'�3l�yyl c2: ,t1�,F7i�(J�'�C'��.
<br /> (Use badc of thts form or a separaCe sheet if necess�ry to answer this question in detail.J
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<br /> Date Signecl:__��tJ ' Signature: � �'�.��, ...iti:;��; ....... . .._.,.__.�
<br /> � �:. `��_........,.._- .
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<br /> )f signed by a representative: � �• ,� r
<br /> Representative's Name: ��i�/ C��'�% "'�'� Telephone: _�7"J ` ����GJ
<br /> Address: — �fif ��o"'�s > G��;G?f� Z_ ��-�lJ�!/.� Ic':i�T� ,S�t� j ���. 1�1�n�`SJ�Ii�Ga
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<br /> Relationship to Qaimant: ;�.G'�"1-r'u,�',�,��"� ,�;� �,,F�?/„� ��1`v���`
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<br /> 2005
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