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To be Date Stamped By Clerk <br /> pf3.... <br /> ®.•'' C of the Board of Supervisors. <br /> Z< County of San Joaquin <br /> CLAIM FOR DAMAGE OR INJURY <br /> 0 <br /> `STRUCTIONS: <br /> epare in ink or typewriter.File original and one copy with Clerk of the Board of Supervisors, <br /> n Joaquin County,222 East Weber Avenue,Room 701,Stockton,California 95202.Use addi- <br /> ,nal paper as necessary. <br /> ame of Claimant: Mr. Delta Funding L.P. <br /> Ms. last First MI <br /> Mme Address/Phone: 5361 N. Pershing, Suite B, Stockton, CA 95207 f <br /> Name/Number/Street City/Statem Code Phone <br /> Sherri Kirk The Kirk Law Firm, 601 University Ave, <br /> ad Correspondence To: — <br /> Name/Number/Street City/State/Zip Code CA 9 825 Phone <br /> hen did Injury or Damage Occur: 1/3/01 <br /> Month/Day/Year Time of Day PM <br /> HERE DID INJURY OR DAMAGE OCCUR: SEE ATTACHED CLAIM <br /> :)W DID INJURY OR DAMAGE OCCUR: SEE ATTACHED CLAIM <br /> entity of County Vehicle: (if applicable) Not applicable <br /> ime(s) of County Employee(s) involved: Robert McClellon (SJCEHD, Public Health Services); <br /> Steve Mindt (SJCEHD� Mike Huggins (SJCEHD); Alan Biedermann (SJCEHD) <br /> HAT INJURIES OR DAMAGE DID CLAIMANT SUFFER: SEE ATTACHED CLAIM <br /> r,g <br /> '_ ® C <br /> M <br /> 1/IOUNT OF DAMAGE OR LOSS: Excess of $10,000 <br /> Property Damage or Medical Bills Loss of Inepi a (, r Expenses <br /> Cost of Repair Past/Estimated Future Past/Futufg <br /> Total Claim Excess of $10,000 f'tT� < <br /> I declar and penalty of perjury that the forgoing is true and correct. CD _.. <br /> cn <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(4/9G) <br />