DocuSign Envelope ID: CFBE6371-9400-4AD3-AD6D-F65DC36B1735
CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABiLITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 MAR 22 PM 3:05
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 $i911.2). 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:
Derric Harrison
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 9373 Haven Ave., Ste. 100, Rancho Cucamonga, CA 91730
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 9/22/2021 TIME: 9:21 • AM CXPM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fuliy and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and lanamarks.
The incident occurred at the intersection of Yucca and Rosewood in Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
Physical assault by an officer of the Rialto Police Department
4. WERE POLICE AT THE SCENE? [XYES • NO WERE PARAMEDICS AT THE SCENE? • YES X 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.
Excessive force
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ TBD 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: $
DocuSign Envelope ID: CFBE6371-9400-4AD3-AD6D-F65DC36B1735 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 intormation (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L - TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: L
DATE: TIME: • AM • PM DATE: TIME: L AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
or all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate pla accident by "X" and by showing house numbers or distances to street corner 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
7 SIDEWALK
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 C THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
DocuSigned by:
SIGNATURE, BEAFLLMANT OR AGENT
Derric Harrison 3/22/2022
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