CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2022 MAY 12 AMII: 57
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:
Andrew Beltran
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 1 BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 05/09/2022 TIME: 7:30 XAM 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.
3. HOW DID DAMAGE OR INJURY OCCUR?
Driving to work, hit pot hole on city street, Pepper/Foothill.
Damaged front passenger tire, needed to replace tire.
4. WERE POLICE AT THE SCENE? • YES INO WERE PARAMEDICS AT THE SCENE? • YES IX 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.
Large pot hole on Pepper and Foothill
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 129.70 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: • 05/09/22 Tire Replaced Amount: $_$129.70
Item/Date: 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: $_
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: () 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
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 THIS ANT.
2x MAY
TY CLERK ECEM OF RIALTO
AM 11: 58
CURB
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.
SIGNATURE OF CLAIMANT OR AGENT
Andrew Beltran 05/09/22
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 1630 E 1st Street Store: 585
HIres LES SCHWAB Beaumont, CA 92223 Invoice: 58500094154 951-845-0505 Salesperson: Edwardo A T
Work Order #: 58500094097 ARD 295212
Customer Information Vehicle Information
Customer ID: A05853735 Vehicle: 2019 HONDA CIVIC
Name: ANDREW BELTRAN Color: WHITE
Address: 14222 CAPEZZAN CIR Mileage: 31,906
City, State, Zip: BEAUMONT, CA 92223 License:
Phone:
Comments: replace right front tire
Les Schwab Invoice
Qty Product Code Product Description Price/ea FET Amount 1 817646 215/50R-17XL 95V STRATUS $94.99 $0.00 $94.99
1 13718 WHEEL SPIN BALANCE $16.99 $0.00 $16.99
1 648662 TUBELESS VALVE STEM $7.99 $0.00 $7.99
Parts Subtotal: $102.98
Labor Subtotal: $16.99
Sales Tax: $7.98
Tire Tax: $1.75
Invoice Total: $129.70
Payment Method: DEBITCRD Approval# 013720 Card# XXXXXXXXXXXX0372 $129.70 DOT: Tire(s) has been electronically registered.
Wheel Position: RF
Notes To Review REPLACED RIGHT FRONT TIRE
With Customer:
Service Checklist:
Visual Tire Inspection | Comments: ALL 6/32ND
Tire Pressure Check | Comments: SET TO 35 PSI
Visual Wheel Alignment | Comments: RECOMEND CHECK EVERY 6 MONTHS Front End Component Check | Comments: NO LOSSE COMPONETS Visual Shock/Strut Inspection | Comments: NO VISABLE LEAKS Visual Brake Inspection | Comments: 8MM FRONT PADS
Remember to rotate your tires every 5,000 miles for maximum mileage - and it's free! Les Schwab electronically registers your tire purchase with the tire manufacturer at no charge to you, in accordance with NHTSA's tire registration requirements.
Invoice Date/Time: 05-09-2022 05:37 PM Page 1 of 2
Andrew Beltran
SN BERNARDINO CA 923
10 MAY 2022 PM 6 L
Rialto City Clerk's Office
CITY OF RIALTO 2022 MAY 12 AMI: 57 RECEIV.. CITY CLERA 150 S. Palm Ave.
Rialto, CA 92374
92376-648799