CITY OF RIALTO CITY CLERK'S DATE STAMP
Op- CITY OF RIALTO
LIABILITY
2022 SEP 12 AM||: 37
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).
3.READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
4.ATTACH SEPARATE SHEETS. IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Maria Hernandez
FULL NAME
DATE OF BIRTH
Private Private
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 200 Spectrum Center Dr, Ste 1230, Irvine, CA 92618
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE 200 Spectrum Center Dr, Ste 1230, Irvine, CA 92618
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
08/05/2022 11:35
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: TIME: • AM CX 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.
Riverside Ave and Agua Mansa Rd
3. HOW DID DAMAGE OR INJURY OCCUR?
Maria was the driver in a vehicle that was t-boned by a Rialto police officer. She sustained bodily injuries not limited to her back, and shoulders. She was also psychologically affected, and her property was damaged
4. WERE POLICE AT THE SCENE? ¿ YES NO WERE PARAMEDICS AT THE SCENE? • YES I 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.
Addiontional informtion on Rialto police officier will be on police report with Rialto Police Department.
Report number 932209069
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ areater than $25,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Medical specials Amount: $ TBD
Item/Date: General damages Amount: $ TBD
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: TBD $
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: medial Specials Amount: $_TBD
Item/Date: General damages Amount: $_TBD
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ TBD
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: N/A
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: __) TELEPHONE: L. .)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Integrated Medical Center
NAME:
ADDRESS: 370 W 6th St Suite 100 ADDRESS
San Bernardino, CA 92401
TELEPHONE: (909, 381-3492
TELEPHONE: |_)
DATE: TIME: LOAM PM DATE
TIME: • 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
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
Juan Angeles, Esq. 09/08/2022
TYPE OR PRINT NAME DATE
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
CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 SEP 12 AMII: 39
TO PERSON OR PROPERTY
CITY CLERK 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).
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 RETURN TO:
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:
Jose Desales Lopez
FULL NAME DATE OF BIRTH
Private
Private
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 200 Spectrum Center Dr, Ste 1230, Irvine, CA 92618 1949) 727-9300 BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE 200 Spectrum Center Dr, Ste 1230, Irvine, CA 92618
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 08/05/2022 11:35 - TIME: •I AM 0X 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.
Riverside Ave and Agua Mansa Rd
3. HOW DID DAMAGE OR INJURY OCCUR?
Jose was the passenger in a vehicle that was t-boned by a Rialto police officer. He sustained bodily injuries not limited to his shoulders and back.
4. WERE POLICE AT THE SCENE? * YES NO WERE PARAMEDICS AT THE SCENE? • YES X 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.
Additional information on Rialto police officer will be on police report with the Rialto Police Department.
Report number 932209069
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 5 greater than $25,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: Medical specials Amount: $ TBD
Item/Date: General Damages Amount: $ TBD
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: TBD $_
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: medical specials Amount: $ TBD
Item/Date: general damages Amount: $ TBD
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $. TBD
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) N/A
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
Integrated Medical Center
NAME: NAME:
ADDRESS: 370 W 6th St Suite 100
ADDRESS:
San Bernardino, CA 92401
TELEPHONE: (909381-3492 TELEPHONE: )
DATE: TIME: DATE: TIME: • AM 0] 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
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 OK/AGENT
Juan Angeles, Esq 09/08/2022
TYPE OR PRINT NAME DATE
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
MANAGING PARTNER ASSOCIATES
- LAW OFFICES OF-
Samer Habbas Kristina Akers
SAMER HABBAS Johnny Angeles
Llambrini Duda
- & ASSOCIATES, PC -
Gregory Grigorian
200 Spectrum Center Dr. Ste 1230. Irvine. CA 026Ix Michelle Hunter Faran Imani
habbaspilaw.com/ph: 949-727-9300 | fx: 940.727-0308
Christopher Lee
OF COUNSEL
Jennifer Esced*
Scott Hanssler
sensed top to
Ma hungron
September 8, 2022
Rialto City Clerk's Office
150 S Palm Ave,
Rialto, CA 92376
Tracking No.:
RE: Client Names : Fiorella Hernandez & Jose Desales Lopez Date of Accident : 04/04/2022
To Whom It May Concern:
Enclosed is a Claim for Damages to Person or Property form.
Please notify this office if you should have any questions concerning the above.
Thank you for your anticipated courtesy and cooperation.
Best Regards,
LAW OFFICES OF SAMER HABBAS
Johnny Angeles
Attorney at Law
[email protected]
CITY CLERK RECEIVED 2027 SEP 12 AMII: 39 CITY OF RIALTO
CERTIFIED MAIL
Law Offices of Samer Habbas PITNEY BOWE!
$7.82°
US POSTAGEIMI
Associates inc. P.C.
200 Spectrum Center Drive Ste 1230 7022 2410 0000 2162 4559 Irvine CA 92618
CITY
PIrDY RECEIVED 2022 SEP 12 AMII: 39 CITY OF RIALTO
Riaito City Cerk's Office
X8370 A
150 S Palm Ave
03A1303
Rialto CA 92376
21 d3 .u
S237686487 CO02