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p5 t1 a N,• �, To be Date Stamped By Clerk <br /> �•' •OG of the Board of Supervisors. <br /> Y' <br /> $' County of San Joaquin <br /> e'• :e <br /> CLAIM FOR DAMAGE OR INJURY <br /> q�iFo.R� <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. <br /> Last First Mt <br /> Home Address/Phone: 5361 N. Pershing, Suite B, Stockton, CA 95207 <br /> Name/Number/Street City/State/Zip Code Phone <br /> Sherri Kirk 601 Univ rsity Ave, <br /> Send Correspondence To: Dt-nn;s .T- Pr;n1na The Kirk Law Firm, Sir to 262,qgc t (916) 9167-19&0— <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 /> Vame(s) of County Employee(s) involved: Robert McClellon (SJCEHD, Public Health Services) ; <br /> Steve Mindt (SJCEHD); Mike Huggins (SJCEHD) ; Alan Biedermann (SJCEHD) <br /> NHAT INJURIES OR DAMAGE DID CLAIMANT SUFFER: SEE ATTACHED CLAIM <br /> R <br /> AMOUNT OF DAMAGE OR LOSS: Excess of $10,000 <br /> Property Damage or Medical Bills Loss of Incpit)e u,.� i r Expenses <br /> Cost of Repair Past/Estimated Future Past/Future, - <br /> Total Claim Excess of $10,000 j =n < <br /> 1 declar and penalty of perjury that the forgoing is true and correct. ci <br /> N <br /> Attorney 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(4/96) <br />