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Did the incident involve a ❑ Yes <br />'-ity employee, vehicle, <br />or other equipment? ® No <br />Describe damage, injury. <br />indebtedness, obligation, or loss <br />incurred as of claim date_ <br />Claim Information: <br />Total Amount of Claim: <br />'List of Clain Items: <br />(Attach copies of all receipts/ <br />quotes, and photographs.) <br />If Yes, please list name and department (if known), vehicle number, type of equipment, etc. <br />If the claim is less than $10.000 amount must be noted on "Total Amount of Clain" line. <br />If the claim amount is more than S 10,000, no dollar amount need be included, but you must indicate <br />whether jurisdiction would rest in the : <br />❑ Municipal Court (claim value of more than S10.000 but less than S25,000): or <br />®(Superior Court (claim value of more than S25,000) <br />Amount Description <br />Declaration: <br />This claim shall be dated and signed by the claimant or by some person on his/her behalf. A claim relating to a cause of <br />action for wrongful death, personal injury, damage to personal property, or growing crops shall be presented not later <br />than six (6) months after the aceival of the cause of action. There may be other statutes governing this claim, including, <br />but not limited to, certain Federal statutes. You may seek the advice of any attorney in connection with this matter. <br />Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may <br />be subject to fines and confinement in state prison. <br />Date 3/9/2026 Signature: <br />Print Name: Jinny Kim <br />Relationship (if other than claimant): Attorney <br />Veision 3!U1_025 <br />G.`Risk v 2mf Fomv Claim Fors <br />City of San Leandro - Clain for Money or Damages Page 2 <br />