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1 ' <br /> 7QU f/y To be Date Stamped By Clerk <br /> of the Board of Supervisors. <br /> y: County of San Joaquin <br /> CLAIM FOR DAMAGE OR INJURY <br /> INSTRUCTIONS: <br /> Prepare in ink or typewriter. File original and one copy with Clerk of the Board of Supervisors, <br /> Ian Joaquin County,222 East Weber Avenue, Room 701,Stockton,California 95202. Use addi- <br /> .ional paper as necessary. <br /> Name of Claimant: Mr. Delta Funding L.P. <br /> Ms. Last First MI <br /> Home Address/Phone: <br /> 5361 N. Pershing, Suite B, Stockton, CA 95207 f ) <br /> Name/Number/Street City/State/Zip Code Phone <br /> Sherri KirkThe Kirk Law Firm, 601 Univ rsity Ave, <br /> Send Correspondence To: Danns .T_ Pr;n1n Suite 962_ Sac (26) 567-3960L--- <br /> Name/Number/Street City/State/Zip Code CA 95825 Phone <br /> When did Injury or Damage Occur: 1/3/01 <br /> Month/Day/Year Time of Day PM <br /> WHERE DID INJURY OR DAMAGE OCCUR: SEE ATTACHED CLAIM <br /> -IOW DID INJURY OR DAMAGE OCCUR: SEE ATTACHED CLAIM <br /> dentity of County Vehicle: (if applicable) Not applicable <br /> slame(s) of County Employee(s) involved: Robert McClellon (SJCEHD, Public Health Services) ; <br /> Steve Mindt (SJCEHD); Mike Huggins (SJCEHD) ; Alan Biedermann (SJCEHD) <br /> KHAT INJURIES OR DAMAGE DID CLAIMANT SUFFER: SEE ATTACHED CLAIM <br /> kMOUNT OF DAMAGE OR LOSS: Excess of $10,000 7. <br /> Property Damage or Medical Bills Loss of Incoi4c r I r Expenses <br /> Cost of Repair PastlEstimated Future Past/Future; _ <br /> Excess of $10,000 - < <br /> Total Claim " ' <br /> I declar and penalty of perjury that the forgoing is true and correct. CD .. <br /> Attorney ( fD 12/04/01 <br /> Signature Relationship to Signer,if not the Claimant Date <br /> White-County Counsel <br /> Yellow-County Counsel NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY <br /> Pink-Claimant Pers.8(9/96) <br />