CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2022 APR 22 AMII: 51
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:
MIGUEL VALENCIA 1/31/76
-
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. 81 8- 347-6230
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Law office ofticibay Wabby
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 21031 ventura Bud, #921, Wondland His Craw
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 414/22 TIME: 7:00 AMOPM
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.
FRISBIE PARK 1901 NACACIA AVE RIALTO CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
MIGUEL WAS WALKING HIS DOG. STEPPED ON SPRINKLER
COVER. COVER FLIPPED OVER AND HIS FOOT WENT INSIDE AND
HE FELL FORWARD.
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? • YES CKNO
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.
Sustained INJURY TO KNEE, NECK AND BACK,
Shoulder & rightankte
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage sunknawat this HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates time DAMAGES INCURRED TO DATE:
Item/Date: Uncertained at THE Amount: $
Item/Date: MOMENT. 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: §Unknownat
tristime
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:
NAME: San Bern. Comm. Hose.
ADDRESS: 1805 MedicalCtr. Dr.
San Bernardino, CA 92411
TELEPHONE: 9091 887-10333 TELEPHONE: )
DATE: 44120- _ TIME: — • AM • PM DATE: TIME: •I 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 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 CLERK RECEIVED 2022 AAR 22 CITY OF
PARKWAY
71 SIDEWALK
AMII: 51 RIALTO
Secattached
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.
ICEDTIC AD DECLARELUNDER DENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Walter J. Wadby 441822
TYPE OR PRINT NAME
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 HOT
COALS
ONLY
LAW OFFICE OF WABBY & WABBY
A PROFESSIONAL CORPORATION
Walter J. Wabby, Esq. - [email protected]
Matthew D. Wabby, Esq. - [email protected]
21031 Ventura Boulevard Telephone: (818) 347-6230
Suite 921 Facsimile: (818) 347-6554
Woodland Hills, California 91364
April 19, 2022
Rialto City Clerk's Office
150 S. Palm Ave.
Rialto, CA 92376
Re: My Client Miguel Valencia
Date of Loss : April 4, 2022
Dear Sir/Madam:
Please file the enclosed Claim for Damages form and return a stamped copy to my office in the envelope provided.
Thank you for your courtesy and cooperation herein. Should you have any questions, please do not hesitate to contact this office.
Very truly yours,
WALTER J. WABBY
WJW:Iso
Encl.
CITY CLERK RECEIVEL 2022 APR 22 AM||: 51 CITY OF RIALTO SANTA CLARITA CA 913asler FIRST-CLASS MAIL
LAW OFFICES OF WALTER J. WABBY
04/19/2022
21031 Ventura Boulevard 20 APR 2022 PM 6 L US POSTAGE$000.73º Suite 921
Woodland Hills, California 91364
ZIP 91364
011D10658599
CITY OF RIALT
Rialto City Clerk's Office
150 S. Palm Ave.
Rialto, CA 92376
S2376-648799