04-13-2026 Council Documents - Regular Meeting

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Claim for Money or Damages Against the r City of San Leandro Return 0aina Fonn To: City Clerk's Office City of San Leandro 835 East 14th Street, San Leandro, CA 94577-3 782 Phone: 510 / 577-3487 Control No_ I ° ` 7 ED f _ This claim against a public entity must be presented as prescribed by Parts 3 and 4 of Division 3.6 of Title 1 of the Government Code of the State of California by the claimant or by a person acting on his/her behalf as well as comply with the Medicare Secondary Payer Mandatory Reporting Provisions in Section III of the Medicare, Medicaid and SCH1P Extension Act of 2007 (see 42 U.S.C. 1395y(b)(T) & (8)). You must use the form provided or another form that satisfies the requirements of California Government Code Sections 910 and 910.2, otherwise your claim may be returned The use of this form is not intended in any way to advise you of your legal rights or to interpret any law. If you are in doubt regarding your legal rights or the interpretation of any law, you may seek legal advice. When failure to present a timely claim occurs (one not within the required statutory six (6) months after the accrual of the cause of action), a written application may be made for leave to present such claim in accordance with the Government Code. The application shall be presented within a reasonable time not to exceed one (1) year after the accrual of the cause of action and shall state the reason for the delay in presenting the claim. The proposed claim shall be attached to the application. Claimant Information: (Please type or print clearly) Gender: Name: Christina Roma Leffmann Date of Birth: Address: Work: ( ) San Leandro, CA 94578 I' City/State/Zip: StatelZip: Home: Notices to be sent to: ❑ Same as above ® Other (please indicate name, address, city, state, zip, phone number and relationship to claimant) Jinny Kim, Attorney, Disability Rights Education & Defense Fund, 3075 Adeline Street, Suite 210, Berkeley, CA 94703, 510-644-2555, ext. 5251 Incident Information: Where did incident occur.' Please provide a detailed description of what happened and attach additional pages if needed. Complete this section if you are a Medicare, Medi-Cal, or SCRIP beneficiary: Social Secm-ity ihi (last 5 digits) or Dedicare MCN: ICD-9 Diagnoses Code: Body Part Code: Date of Incident: Time of Incident: Throughout the past 6 months and continuing. See attached Witnesses: ❑ Yes ❑ No If Yes, list name(s), complete address(es), and phone number(s) Unsure am / pin Over to complete Page 2