Emeryville, CA · Alameda County
Claim Form
The City of Emeryville Claim Form lets a claimant report an injury, damage, or loss and request money from an entity.
What this form is
Use this form to make a claim against an entity for an injury, damage, or loss. It asks for claimant contact details, incident dates and location, what caused the loss, known employee names, specific losses, the amount sought, and how that amount was calculated; a separate sheet may be used for detailed answers.
Who needs it
A person making a claim against an entity for an injury, damage, or loss can complete this form.
How to submit it
Return the form to the City Attorney’s Office, City of Emeryville, 1333 Park Avenue, Emeryville, CA 94608. The form also lists a fax number and email address for return.
About notarization
This form has no notary block; the claimant or representative signs and dates it, and the form lists no notarized or sworn attachment.
How to submit this form
- 1
Download the Form
Download the City of Emeryville Claim Form.
- 2
Complete the Claim Details
Enter claimant, incident, loss, and amount information, then sign and date the form.
- 3
Gather Any Separate Sheets
Use the back of the form or a separate sheet if more space is needed for detailed answers.
- 4
Return the Form
Return it to the City Attorney’s Office at the address shown on the form.
Frequently asked questions
- What information does the Emeryville Claim Form request?
- It asks for claimant and notice-address details, incident dates and location, how the entity caused the loss, known employee names, specific losses, the amount sought, and how it was calculated.
- How do I submit the Emeryville Claim Form?
- Return it to the City Attorney’s Office at 1333 Park Avenue, Emeryville, CA 94608. The form also lists a fax number and email address.
- Do I need a notary for the Emeryville Claim Form?
- No. The form has no notary block; the claimant or representative signs and dates it, and it lists no notarized or sworn attachment.