Item 16A - Claim for Damages Lawrence Boehm.jul 'i t) 1986 ITEM I
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CLAIM AGAINST THE CITY OF POWAY
Received by via tii t': C�.E;%c ,,..rr„rte,
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U.S. Mail
Inter -Office Mail �'� Clerk's Time Stamp
O'ver the.. Counter
JNt) IN SERV DEPT
A claim must be filed with the City Clerk of the Cit of Power
City
which the incident or. event occurred. Be sure your claim is against 100 days after
Foway, not another public entity, Where space is insufficientg the. City of
Paper and identify information b • Please use additional
Y Paragraph number. Completed claims must be mailed
or delivered to the City Clerk, The City of ply. 13325 civic t
c
CA 92064 (P.O. Box. 785).: Cener Drive, Poway.
it TO THE FAN ILE MAYOR AND C.ITy � 0DWCIL, THE CTX QF DCx•1z+v CALT�r, - RMA.
The undersigned respectfully submits the following; claim and informer
damage to persons and/or Personal property: tion. relative to
1. NAND OF CLAIMALIT C=AVL t ,
a. ADDRESS OF CLAiiI w
b. PANE N0. c. D ,
ATE OF BIRTH
d • soclAL sECLjRrrYo..{"e. DR
rvz t s r.c.
2. Nam, telephone and post office address to which claimant desires not'
sent if other than: above:
ices to be
3 Occurrence or event from which the -claim arises -
a. DATE` b. TIME 3C�
ter , C. PLACE (exact and specific location)
_ d. How and under whatcircumstances..
did damage or injury occur? Specify the
Particular occurrence, event., act or emission you claun caused the
injury
damage (use additional paper if necessary) or
1
e. What
Particular action by the City, or its employees, caused the all ed
damage or injury? eg
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2 of 5 JUNI 0 1986 1 T E M
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