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AFH Systems Group - claim 02

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AFH Systems Group - claim 02
250 Hamilton Avenue
P. 0. Box 10250
Palo Alto, CA 94303
Phone: ( )
Address: City/Zip:
Send Notices to:
Date and Time of Occurrence:
Exact Place of Occurrence:*
Describe in FULL DETAIL how the injuries or damages occurred:*
Act or omission by a City employee, officer or agent which caused the alleged injuries or damages:*
Name(s) of City employee, officer or agent allegedly causing the injuries or damages:
Describe full extent of injuries and damages claimed:*
a. If total amount claimed is $10,000 or less at the time of presentation, state amount claimed and the basis of the computation:
b. If total amount claimed is more than $10,000:
- Municipal Court (amount claimed is between $10,000 and $25,000)
___ Superior Court (amount claimed exceeds $25,000)
Names, addresses & telephone numbers of witnesses, doctors, hospitals and any person who can substantiate your claim or amount
claimed: *
Please provide any documents that you believe may support your claim.
*Attach additional sheets if necessary
Signature of Claimant or Person on Claimant's Behalf
971029 9000006

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