CITY OF RIALTO ITY CLERK'S DATE STAMP
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 2022 AUG - | AMII: 43
RECEIVED
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). CITY CLERK
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2).
3. READ ENTIRE CLAIM FOR BEFORE FILING RETUF V TO:
Rialto ity Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 15S. Palm Ave., Rialto, CA 92376 Address 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Leasha Sharnell Taylor 08/0/1993
FULL NAME DATE & BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME ELEPHONE NO.
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: 12:0 • AM XI PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagran on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
Intersection of S. Pepper Ave, & West Mill St., Rialto CA
3. HOW DID DAMAGE OR INJURY OCCUR?
The Rialto Police Department Officer failed to stop for the red traffic light, failed to yiel the right of way, and failed to activate lights and sirens in a timely manner to warn ongoing traffic of his hers attempt to cross said intersection while on a red light.
4. WERE POLICE AT THE SCENE? X 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.
I was driving north bound on Pepper Ave. with a green light. When suddenly a Rialto Police Officer who was traveling east bound on Mills St. ran the red light and crossed the intersectio without lights or sirens on, colliding with my vehicle.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ To be determined.
HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please atta h 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: TBD Amo nt: $ TBD
Item/Date: TBD Amo nt: $ TBD
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ TBD ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: TBD Amo int: $ TBD
Item/Date: TBD
Amo int: $ TBD
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $TBD
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if n cessary) NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: ( ) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Leasha Sharnell Taylor Sincerie Ann Fleming
NAME:
ADDRESS: Rialto CA 92376 Rialto CA 92376
ADDRESS:
TELEPHONE: TELEPHONE:
DATE: 05/09/2022 TIME: 12:30 _DAM X PM 05/09/2022
DATE: TIME: 12:30 • AM XI 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 NEST 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" cation 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.
Pepper tre
N + B S CURB
PARKWAY
SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OVIN 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
Leasha Sharnell Taylor 07/27/2022
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 LOS ANGELES CA 90035 1150 S ROBERTSON BLVD
INJURY ATTORNEYS Lo ADAMSON AHDOOT
US POSTAGE AND FEES PAID
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RIALTO CITY CLERK'S OFFICE 2022 PM 12 L ELES CA 90U
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