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ATTACHMENT A PRESENTING A CLAIM TO THE CITY OF PLEASANTON PLEASE TYPE OR PRINT CLEARLY ALL OF THE INFORMATION REQUESTED ON THE CLAIM FORM. YOU MUST COMPLETE EACH SECTION OR YOUR CLAIM MAY BE RETURNED TO YOU AS INSUFFICIENT. -The following provides specific instructions for completing each section of the claim form. -Attach additional pages if you need more room to provide the requested information. 1. NAME AND MAILING ADDRESS OF CLAIMANT—State the full name and mailing address of the person(s)claiming damage or injury. Please include a daytime and evening telephone number. 2. WHEN DID THE DAMAGE OR INJURY OCCUR?—State the exact month, date,year,and approximate time(if known)of the incident which caused the alleged damage/injury. Under State law,claims relating to causes of action for personal injury,wrongful death, property damage,and crop damage must be presented to the City of Pleasanton no later than six months after the incident date.A claim may be presented in person or by mail. When filing a claim beyond the six-month period,you must explain the reason the claim was not filed within the six-month period.This explanation is called "application for leave to present a late claim". In considering your claim,the City will first decide whether the late claim application should be granted or denied. (See Government Code Section 911.4 for the legally acceptable reasons a claim may be filed late.)Only if your late claim application is granted will the City then consider the merits of your claim. Claims relating to any cause of action other than personal injury,wrongful death, property damage, and crop damage must be presented no later than one year after the incident date. (See Government Code Section 911.2). 3.AT WHICH LOCATION DID THE DAMAGE OR INJURY OCCUR?—Please include street address,city,county, intersection, etc. If possible,also include the Police Report number(if available). 4.WHAT HAPPENED AND WHY IS THE CITY RESPONSIBILE?—Please explain the circumstances that led to the alleged damage or injury.State all facts which support your claim that the City is responsible for the alleged damage or injury. If known,identify the name of the City Department(s)and/or City employee(s)that allegedly caused the damage or injury. S.WHAT DAMAGE OR INJURY OCCURRED?—Provide in full a detailed description of the damage/injury that allegedly resulted from the incident.(What specific damage or injury do you claim resulted from the alleged actions?) 6. CLAIM AMOUNT:-State the specific total dollar amount you are claiming as result of the alleged damage/injury. 7. HOW DID YOU ARRIVE AT THE AMOUNT CLAIMED?—Provide a breakdown of how the total amount that you are claiming was computed.You may declare expenses incurred and/or future anticipated expenses. If you have supporting documentation (i.e., bills, payment receipts,cost estimates) please attach copies of them to your claim. 8.SIGNATURE:-The claim must be signed by the claimant or by the attorney/representative of the claimant.The City will not accept the claim without a proper signature.Government Code Section 910.2 provides: "The claim shall be signed by the claimant or by some person on his [or her] behalf." 47IPage