CITY CLERK'S DATE STAMP
CITY OF RIALTO CITY OF RIALTO
LIABILITY
2022 MAR 29 PM 4: 57
CLAIM FOR DAMAGES
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). 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:
mântú Alvenice Mosley -
DATE OF BIRTH
FULL NAME
'Ave
HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
Rialto Ca 92376 L
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
Would have if Wallet
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM not lost by Officer (if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 3-25 - 22 TIME: 2007 • AM • 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.
Cavalın restuarant officer takes my personal
property when I get it back on release on 32622
my wallet and main porse money wisen loud and pates
3. HOW DID DAMAGE OR INJURY OCCUR?
The offer deralected his duty he should know
if I did I would have my n roperty in loll
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.
He did not do his son correctly that is what
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 128 " 304 in chagg 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: $.
$ 131"0 132"
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: 10:00
Amount: $.
Item/Date: 3-25-2z Wallet
Amount: $.
Item/Date:
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: L
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: ( • AM LI PM
DATE: TIME:
TIME: • AM • PM
DATE:
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. 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 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 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
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. ... i.
SIGNATURE OF CLAIMANT OR AGENT 3- 28-2022
Mârt Alvenke MoslEy
DATE
TYPE OR PRINT NAME
Me
RELATIONSHIP TO CLAIMANT
RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - S. PALM AVE., RIALTO, CA 92376 NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72)