CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 JAN 27 AMIO: 37
TO PERSON OR PROPERTY
RECEIVED
CITY 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).
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:
Pablo Chavez Ortiz
-
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Carrazco Law, A.P.C., 18301 Irvine Boulevard, Tustin, CA 92780 (Attorneys) BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Carrazco Law, A.P.C., 18301 Irvine Boulevard
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
Tustin, CA 92780 (See attached correspondence for more information) (if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 08/06/2021 TIME: 04:41 MAM OPM
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.
Intersection of South Willow Avenue and West Rialto Avenue, City of Rialto. See attached correspondence and attached Exhibits A-D as described therein.
3. HOW DID DAMAGE OR INJURY OCCUR?
On or about 02/06/2021, Rialto Police Department Officer Dionisio Paul Chavez, while operating a City of Rialto Police Department vehicle on Willow Avenue, made an unsafe, high speed left turn onto Rialto Avenue, striking Claimant Pablo Ortiz, who was lawfully in the crosswalk. Pablo sustained severe and life-threatening injuries as a result of the impact. See attached correspondence and Exhibits A-D as described therein for more information.
4. WERE POLICE AT THE SCENE? MYES•NO WERE PARAMEDICS AT THE SCENE? MYESCINO
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.
Rialto Police Department Officer Dionisio Paul Chavez made an unsafe, high speed left turn while operating a City of Rialto Police Department vehicle from Willow Avenue to Rialto Avenue while in the course and scope of employment. This negligent conduct was the proximate cause of Claimant Pablo Chavez Ortiz's severe life threatening injuries as a result of the impact. See attached correspondence and Exhibits A-D as described therein for more information.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage § See attached correspondence HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Arrowhead Regional Medical Center Amount: §See attached correspondence Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: § See attached correspondence ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Surgeries to leg, arm Amount: $ See attached correspondence Item/Date: Physical therapy, treatment Amount: $ See attached corespondence TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: § See attached correspondence
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: See attached correspondence NAME: See attached correspondence ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Arrowhead Regional Medical Center NAME: See attached correspondence ADDRESS: 400 N. Pepper Avenue ADDRESS:
Colton, CA 92324
TELEPHONE: L - 909-580-0060 TELEPHONE: | )
DATE: 08/06/2021 TIME: 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 comers. 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 vehic hen 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 th 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.
AM IO: CLERK
RECEIVED
<<<West Rialto Avenue >>> X Approximate Location of Incident - CURB occurred in crosswalk at this
CIT intersection
PARKWAY
SIDEWALK
«South Willow Ave.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Christopher L. Holm, Esq. 01/26/2022
TYPE OR PRINT NAME DATE
Attorney
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