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FORM 5.2 Page 1 of 2 CLAIM AGAINST THE CITY OF EL CERRITO Street Apt. No. Address where notices should be sent if different from claimant’s address: Name Business/Company Street Apt. No. City State Zip Date of Incident: Time of Incident: AM or PM Location of Incident: CAUSE OF LOSS: What happened and why is the City responsible? Detailed description of the event, act, or omission which you allege caused the injury or damage for which you are submitting this claim. Please use additional paper if necessary: City Clerk Date Stamp City State Zip Telephone Email Address Pursuant to Government Code 910, subject to certain limited exceptions, a claim must be filed with the City of El Cerrito within six months of the incident. Completed forms must be mailed, hand-delivered or emailed to: City Clerk, City of El Cerrito, 10890 San Pablo Avenue, El Cerrito, CA 94530 or [EMAIL REDACTED] Emailed claims must include scanned original or digital signature(s). Please complete each section and print clearly. Attach any invoices, receipts, estimates, photos, or other documentation that support the claim for damages. Personal service of claims can be accomplished during regular City business hours (Mon., Wed., and alternate Fri. 8:00 a.m. to 4:00 p.m.; Tue. and Thur. 8:00 a.m. to 6:00 p.m.; Closed every other Fri.) excluding City holidays. If you wish to receive a stamped copy of your claim, return the form to the City Clerk with a cover letter along with a stamped, self addressed envelope informing the City of your request. You will receive a letter from the Risk Management Office indicating your claim has been received and is being investigated. You will receive an explanation of the investigation results within 45 days in most instances. Claims relating to any cause of action other than personal injury, wrongful death, property damage, and crop damage must be presented no later than one year after the incident date. (See Government Code Section 911.2). PLEASE TYPE OR PRINT CLEARLY ALL OF THE INFORMATION REQUESTED ON THE CLAIM FORM. YOU MUST COMPLETE EACH SECTION OR YOUR CLAIM MAY BE RETURNED TO YOU AS INSUFFICIENT. Claimant’s Full Legal Name: Driver’s License State & No.: Cell/Home Phone: Business Email: Claimant’s Address: To submit electronically, download the form and open in Adobe Reader Clear Form ---PAGE BREAK--- FORM 5.2 Page 2 of 2 Name(s) of Public Employee(s) causing injury, damage, or loss: Name, email address, and telephone number of any known witnesses: DESCRIPTION OF LOSS (Describe injury, property damage, or loss. If there were no injuries, state "No Injuries.”): AMOUNT CLAIMED (only if less than $10,000): How did you arrive at the amount claimed? - You may declare expenses incurred and/or future, anticipated expenses. If you have supporting documentation (i.e. bills, payment receipts, cost estimates), please attach copies of them to your claim: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - If the amount exceeds $10,000, please check the court for appropriate jurisdiction: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Municipal Court (claims up to $25,000) Superior Court (claims over $25,000) Under State law, claims relating to causes of action for personal injury, wrongful death, property damage, and crop damage must be presented to the City of El Cerrito no later than six months after the incident date. Please note that evidence of "presentation" includes a clear postmark date on an envelope, or a certification of personal service, or service by mail or a confirmation via email reply. When filing a claim beyond the six-month period, you must explain the reason the claim was not filed within the six-month period. This explanation is called "application for leave to present a late claim". In considering your claim, the City will first decide whether the late claim application should be granted or denied. (See Government Code Section 911.4 for the legally acceptable reasons a claim may be filed late.) Only if your late claim application is granted will the City then consider the merits of your claim. If, after reading these instructions, you have questions or need additional information regarding the filing of a claim with the City of El Cerrito, please contact (510) 215-4315. The claim must be signed by the claimant or by the attorney/representative of the claimant. The City will not accept the claim without a proper signature. Government Code Section 910.2 provides: "The claim shall be signed by the claimant or by some person on his/her behalf." I certify that the forgoing is true and correct. Submitted by: Claimant Date: Printed Attorney or Representative Print WARNING: It is a criminal offense to intentionally file a false or fraudulent claim and is punishable by imprisonment for up to one year or a fine of up to $10,000 or both (Penal Code Section 72). (Use to sign, submit and scan via email to [EMAIL REDACTED]) (Use to submit electronically - must be signed electronically prior to selecting the "Submit" button) SIGN SIGN Print Submit