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ATTACHMENT A <br /> CLAIM PRESENTED TO THE CITY OF PLEASANTON <br /> Please read the instructions on the back before completing. 1. Reserved for Filing Stamp <br /> Claimant's Name: (Please Print) City Claim No.: <br /> Claimant's Address: <br /> City, State,Zip: <br /> Day Phone: () Eve: () <br /> 2.When did the damage or injury occur? <br /> Month:Day: Year: Time: a.m.or p.m. <br /> 3.At which location did the damage or injury occur?Police Report No. (if available): <br /> 4. a.What happened and why is the City responsible? <br /> b.Name and position of responsible City Employee(s), if known: <br /> 5. What damage or injury occurred? <br /> 6. Claim amount: <br /> 7.How did you arrive at the amount claimed?Please attach documentation. <br /> 8. I declare that the information provided above is true and correct,and that this declaration was executed on ,20 ,at <br /> CA. <br /> Signature of Claimant or Representative <br /> 9.Official Notices and Correspondence-If represented by an insurance company or an attorney,provide the following information: <br /> Name and Capacity: (please print) <br /> Address: <br /> City, State,Zip: <br /> Day Phone: Eve.: <br /> 46IPage <br />