CITY OF RIALTO CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY 2022 JUN 21 AMII: 44
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:
Melinda Dianna Ferguson
FULL NAME DATE OF BIRTH
Rialto, CA 92377 ( 323)303-3533 ext 14
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: - 05/30/2022 TIME: 7:00 • AM X 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.
Sidewalk on N Palmetto Ave, CA 92377
3. HOW DID DAMAGE OR INJURY OCCUR?
Ms. Ferguson was walking when suddenly she tripped and fell due to an uneven sidewalk on Palmetto Ave. Ms. Ferguson fell forward hitting her face on the ground
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.
The City of Rialto failed to provide safe premises to its citizens. he total amount will b
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage determined at the tri 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: $
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: | 1 TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS:
TELEPHONE: (
DATE: TIME: •AM • PM DATE: TIME: • AM • PN
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 ECEIVED 2022 JUN 2|1 AM||: 44 CITY OF RIALTO
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.
SIGNATURE OF CLAIMANT OR AGENT
Stephan Airapetian 1n6/15/22
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
N Paren
CERTIFIED WATL
$7.330
CLARITA CA US POSTAGE
Stephan Filip PC
FIRST-CLASS 6467996000S690
100 W Broadway Suite 1040 2022 PM 5 1 FROM 91210
JUN 15 2022
Glendale, CA 91210 stamps
endicia
7021 0950 0001 5086 8077
RIALTO CITY CLERK'S OFFICE
CITY OF RIALTO 2022 JUN 21 AMI|: 44 RECEIVED CITY CLERY 150 S PALM AVE RIALTO CA 92376-6406
S237686487 CO02 blmpphlo@poafobgpghbjln