CITY CLERK'S DATE STAMP
HAMO, CAL CITY OF RIALTOTY OF RIALTO
LIPORA LIABILITY.
2022 JAN -7 PM 12: 18
CLAIM FOR DAMAGES
TO PERSON OR PROPERFYEIYED
CLERK
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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
jacqueline Gutierrez
-
FULL NAME DATE OF BIRTH
Rialto CA 92376
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. / Celi BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: July 8, 2021 TIME: 5:25
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.
Inside the Metrolink station parking lot, located at 261 s. Palm Ave in Rialto Calitornia. I left my car parked on July 8, 2021 at 6:05 am and returned later that day at >.25pm to find my car window shattered.
3. HOW DID DAMAGE OR INJURY OCCUR?
I take the train four days a week to go to work in Claremont. On July 8, 2021 When I got off the train at 5:25pm I discovered my broken passenger Side window with glass all over the suvrounding area I am still traumatized
4. WERE POLICE AT THE SCENE? EYES NO WERE PARAMEDICS AT THE SCENE? • YES KNO bythis incident.
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.
Vandalism due to lack of adequate surveillance on the Rialto Metrolink station parkling lot contributed to my window being shattered. One of the security quara's assigned that day named Morgan mentioned nameless people
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 247.15 loitering HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates. * * D Repair pill and 2) Police Report estimate of damage.
DAMAGES INCURRED TO DATE:
Item/Date: Jill 8, 2021 (Broken window) Amount: $. 220.00 Item/Date: July 8, 2021 Police Report Amount: $ 27.15
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 247.15 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hem/Date: Vuly 10, 2021 5149 (Window Repair) Amount: $ 220.00 Item/Date: August 6, 2021 (Police Report) Amount: $ 27•15 TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 247.15
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Securily Guard Morgan NAME: Officer • Blue
ADDRESS: — ADDRESS: 15o S. Palm Ave
Rialto, CA 92376 Rialto, CA 92376
TELEPHONE: (800) 371-5465 TELEPHONE: 909) 820-2550
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A NAME: _
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: )
DATE: TIME: L AM • PM DATE:
TIME: •AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY: N/A
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.
CURB
PARKWAY
/ SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS IOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRL I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Jacqueline Gutierrez 01/07/22
TYPE OR PRINT NAME DATE
self
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