CITY CLERK'S DATE STAMP
CITY OF RIALTITY OF RIALTO
LIABILITY
2022 SEP 16 PM 5:23
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY VED
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:
armen Alice Gomer
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP T HOME TELEPHONE NO.
Rialto, Ca 92316
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE same
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
around
1. WHEN DID DAMAGE OR MAURY OCCUR? DATE MOn. Aug 22, 2022 TME:. 600
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?
Hitch Fork feel off the Rialto City
heavy duty TrucK.
4. WERE POLICE AT THE SCENE? • YES ENO WERE PARAMEDICS AT THE SCENE? DYES DO
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.
A ely worker eveig the maintenade Truck
driving d about 40 m/s per hre
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Drownside door handle Amount: $
Item/Date: Driver'sside door scratch Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 9,0000 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: _ toe, and ankle injury
Amount: $.
Item/Date:
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 9,0000
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: _ dentino Miranda Sesaro Rangel
ADDRESS:
ADDRESS:
Fontana. Ano San Doranarns Cas
TELEPHONE:
TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
vro Santana
NAME:
ADDRESS: 400 Wolamber Ral.
ADDRESS:
Breacal
TELEPHONE:
TELEPHONE: (
DATE: Sep 2,2022 TME:
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. 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. h
second
CuRES. Willow Ave
PARKWAY Merri
7 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. }CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
armen Alice Comer 9-14-22
TYPE OR PRINT NAME
DATE
RELATIONSHIP TO CLAIMANT
RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) On august 22, 2022 arround diaRiem.
my friend Valentino M. and largelan 2021 SEP 16 Pe F223 Parked
CITY CLERK
across the st on willow sve. from where
I live facing North about 8 ft. from the
corner of secondSt. We were putting some
stuff that were left from somebody's yard
sale in the trunk of my car. I suddenly.
hear a metal noise that hit metal and
that's when I feel the blow on my left
toe and my left ankle, then I see the
city track, maintenance truck. I screamed
loud. I was in pain, my friend said, what
happened, what hit you. I started crying
at that time I didn't know what it was,
but my friend sow the hitch fork under my
car, I was sure the truck'" was going to
stop because I saw the break lights, I was
sure he heard my scream. byt he keep
driving and never returned, He knew if
was able to see the round Bialto city logo
on the heavy dury thack. I was all dress up
to attendi dinner for my dauginters birthday
and I had to cancelled because I was in
1 of 2
, a lot of pain that went all the way to
the hip and thigh and may left ankle was
red that later turned purple as well as my
toe. I was wearing open toe sandals and
my nail broke as well. A delivery man
carrying beds was parked on willow Are.
facing south told me that he saw
the fork that flew off the city truck.
and he's willing to testify as well as
my friend Valentine. The metal fork hit
the handte of the driver's door and broke
it and it scrached l inches too. I went
in person to talked to the city maintenance
and they said they were going to get in touch
with me but I went back a second time but
they did not. They said they were going to
investigate and asked me to leave the Hitch
Fork with them, I only know that aeday
- name was Mike. on arrow Ave.
A 110
03A13038 Caine ate long
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