CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 FEB -7 PM 3: 34
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 RETURN TO:
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:
Alyssa Rubio
FULL NAME DATE OF BIRTH
Rialto, CA 92376
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 Stephan Filip PC 100 W Broadway Suite 1040
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Glendale, CA 91210
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 11/10/2021 TIME: Around 8:00 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.
Carter High School 2630 N Linden Ave Rialto, CA 92377
3. HOW DID DAMAGE OR INJURY OCCUR?
Ms. Rubio was violently attacked on the premises of Carter High School.
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 provide safe premises for its citizens.
The full medical report and
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ bills will be provided upon receipt.
HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: The full medical report and bills will be provided upon receipt. Amount: $_ Item/Date: Amount: $.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 5- 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:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: ( TELEPHONE: (
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
The full medical report and bill will be provided upon receipt NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: | 1
DATE: TIME: DATE: TIME:
WAM •I 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.
CURB
CITY 2022 FEB - 7
PARKWAY
RECEIVED
SIDEWALK CLERK CITY OF RIALTO
PH 3:
34 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 (ORDECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF GLAIMANT OR AGENT
Stephan Airapetian 02/02/2022
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
CERTIFIED MAIL
$7.330
ARITA CA US POSTAGE
Stepnan Filip PC FIRST-CLASS 062S0011403997
100 W Broadway Suite 1040 :22 FROM 91210
FEB 04 2022
Glendale, CA 91210 stendicia
7021 0350 0000 8808 1445
Rialto City Clerk's Office
150 S. Palm Ave.,
Rialto CA 92376-6406 CITY CLERK RECEIVED 2022 FEB -7 PM 3: 34 CITY OF RIALTO 92375-848799 glyphumble