CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2021 DEC 17 PM 3:59
TO PERSON OR PROPERTY
ALOCITED
CITY CLERA
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Francisco Elias Galvez
FULL NAME DATE OF BIRTH
Adelanto, CA 92301
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Downtown LA Law; 601 N. Vermont Ave., Los Angeles, CA 90004
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): (213) 389-3765
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 06/15/2021 TIME: • AM 0 PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
At or near 1998 N. Arrowhead Ave., San Bernardino, CA 92405
3. HOW DID DAMAGE OR INJURY OCCUR?
Mr. Galvez was provided a Cpap machine by Arrowhead Regional Medical Center that caused him to sustain injury.
Injuries include but are not limited to burn on back of Mr. Galvez's head.
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? • YES//NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
The city of Rialto failed to properly hire, train, supervise, employ and/or manage their Arrowhead Medical Center employees. The employees failed to provide proper medical care and failed to warn the general public of a dangerous condition.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ Pending HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $ Pending
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1,000.000.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ Pending
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: | )
DATE: TIME: • AM • PM DATE: TIME: •AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street corners.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X".
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CITY
CURB CITY OF RIALTO
PARKWAY
//F SIDEWALK
THOSE MATTERS MICH ARE HEREN STATED UPON MY NERATION AND BELE AND AS TO THOSE MATES BELIEVE THEM TO BE EXCEPT AS TO I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Jazmin Ramos OBO Francisco Galvez 12/13/2021
TYPE OR PRINT NAME DATE
_Legal Assistant @ DILA Law
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 USPS CERTIFIED MAIL™
Jazmin Ramos $4.28 US POSTAGE
601 N VERMONT AVE FIRST-CLASS
LOS ANGELES CA 90004-2174 Dec 13 2021 3:5
USPS CERTIFIED MAIL Mailed from ZIP 90004
1 oz First-Class Mail Letter
11923275
062S0012913542
9407 1118 9876 5845 8676 46
CITY OF RIALTO 2021 DEC 17 PM 3:59 CITY CLERI
Rialto City Clerks Office
150 S PALM AVE
RIALTO CA 92376-6406