Laserfiche WebLink
To be Date Stamped ny Cleric <br /> !'•9G of the Board of Supervisors. <br /> ,t <br /> County of San Joaquin <br /> CLAIM FOR DAMAGE OR. INJURY <br /> �LfAOaa <br /> INSTRUCTIONS: <br /> Prepare in ink or typewriter.File original and.one copy with Clerk of the Board of Supervisors, <br /> San Joaquin County,222 East Weber Avenue,Room 701,Stockton,California 95202.Use addi- <br /> tional paper:as necessary. <br /> Name of Claimant: Mr Delta Funding L.P. <br /> MA MI <br /> Home Address/Phone: 5361 N. Pershing, Suite R, Stockton, CA 95207 <br /> Name/Nambc/Stieet <br /> Sherri Kirk � p9r01 University A�rei <br /> Send Correspondence To: ,. The Kirk Law Firm, 561 <br /> _ <br /> Name/Numbar*eet city/Stawzip coda CA 9 825 Phone <br /> When did Injury or Damage Occur: 1/3/01- <br /> I <br /> Month/Day/year Time of Day PM <br /> WHERE DID INJURY OR DAMAGE OCCUR SEE ATTACHED CLAIM <br /> KOW DID INJURY OR DAMAGE OCCUR SEE ATTACHED CLAIM <br /> dentity of County Vehicle: (if applicable) Not applicable <br /> dame(s) of County Employee(s) involved: Robert McClellon (SJCEHD, Public Health Services); <br /> Steve Mindt (SJCEHD); Mike Huggins (SJCEHD); Alan Biedermann (SJCEHD) <br /> VHAT INJURIES OR DAMAGE DID CLAIMANT SUFFER: SEE ATTACHED CLAIM <br /> ,MOUNT OF DAMAGE OR LOSS: Excess of $10,000 <br /> Property Damage or' Medical Bala Loss of Income other Expemas <br /> Coo of Repair Past/Eoimated Future PaWFumm <br /> Total Claim Excess of $10,000 <br /> I decla and penalty of perjury that the forgoing is true and correct <br /> Attorney 12/04/01 <br /> Sirmnua Retatimahip to Signer,if not the Claimant Data <br /> White-County Counsel <br /> Yellow-County Counsel NOTE PRESENTATION OF A FALSE CLAIM IS A FELONY <br /> Pink-Claimant Pea 8(4/961 <br />