CITY OF RIALTO CITY CLERGYATE STAMP
OF
LIABILITY 2022 JAN 26
RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY CITy RECEIVED 3: 32
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: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Francisco PERALTA 5-22-58
FULL NAME DATE OF BIRTH
1869 N. Millard Ave, Rialto, CA 923766 1909, 470-0166
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: |2-14 - 21 TIME: 4:00 DAM 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. in my home.
3. HOW DID DAMAGE OR INJURY OCCUR?
Tree fell over onto vehicle
4. WERE POLICE AT THE SCENE? YES 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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage = 2l0e.°° 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: $_
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
$.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $
Item/Date:
Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Silvia Perala Sabrina
NAME: _
ADDRESS: 1809 N. Millard Ave 1879 N. Millard Ave
ADDRESS:
Rianto CA 92376 Rialto CA 92376
TELEPHONE: |)
TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: )
DATE: TIME: DAM OPM
DATE: _TIME:
ДАМ 0 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.
HOUSE
CURB
& PARKINAY-
SIDEWALK
t Tree
Millard.
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Cunde Peact
SIGNATURE OF CLAIMANT OR AGENT
CYNDI PERALTA 1-76-70
TYPE OR PRINT NAME
DATE
Daughter
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150S. PALM AVE., RIALTO, CA 92376 JAN 6, 2022 COUNTER SALES TOYOTA OF SAN BERNAR V51/4505 2525 INVOICE# CUST # NAME PHONE PAY CTR# PL
5469 200
LN# PART# / DESCRIPTION QORD QSHP SALE CORE EXTENDED TC PL 90950-01956 PLUG, HOLE 1 1 3.74 3.74 S 200
2 65759- 0C030 COVER, TAIL GA 1 1 186.99 186.99 S 200
65700- 0C073 GATE ASSY, RR 1 1 639.53 639.53 200
65405 - 0C040 BOARD SUB-ASSY 1 1 480.29 480.29 S 200
65483 - 0C011 RAIL, HEADER B 1 159.67 159.67 S 200
65717- 0C051 PROTECTOR, TAI 1 1 147.54 147.54 200
7 69090- 0C051 HANDLE ASSY, B 1 1 122.11 122.11 S 200
8 65768- 0C010 STRIKER, TAIL 2 11.72 23.44 S 200
65780 - 0C041 LOCK ASSY, 45.14 200
LOCK ASSY, TAI 45.14 200
TOTAL 2606.62
(A=ADD) (D=DELETE) (E=ENTER) (CR=CONS REACH) (M=MODIFY) (N=NBRS) (TAB) JAN 6, 2022 COUNTER SALES TOYOTA OF SAN BERNAR V51/4505 2525 INVOICE# CUST # NAME PHONE PAY CTR# PL
5469 200
LN# PART# / DESCRIPTION QORD OSHP SALE CORE EXTENDED TC PL - - - - - - - -
11 65655- 0C011 LINK, TAIL GAT 1 1 13.62 13.62 200
12 65656 - 0C011 LINK, TAIL GAT 1 1 14.83 14.83 S 200
13 69749-34010 CLAMP, DOOR LO 2 2 2.16 4.32 200
14 86790-34030 CAMERA ASSY, T 1 1 720.26 720.26 S 200
AVAI LIST COMP ASSOC
BN1 TRADE STS SRC COMPNT
BN2 COST GRP ALTER GP%
NEW# OLD#
REMARKS TOTAL 2606.62
(A=ADD) (D=DELETE) (E=ENTER) (CR=CONS REACH) (M=MODIFY) (N=NBRS) (TAB)