CITY OF RIALTO
2022 OCT -3 PM 5:21
GASTÉLUM LAW RECEIVED
CITY CLERK
767 WORSHAM AVE., LONG BEACH, CALIFORNIA 90808-177
213) 340-6112 | [email protected]
September 28, 2022
Sent Via Certified Mail, RRR,
Article No. 7021-0350-0001-1195-6030
Rialto City Clerk's Office
150 S. Palm Ave.,
Rialto, CA 92376
Re: Government Claim
Claimants: Estate of Irene Jaramillo, Isabel Jaramillo, Julian Ramos, Jr., Roberto Ramos
Date of Incident: April 2, 2022
To Whom It May Concern:
Enclosed please find four Government Claims pursuant to California Government section 910 presented to the City of Rialto, both an original and a copy, for filing on behalf of claimants Estate of Irene Jaramillo, Isabel Jaramillo, Julian Ramos, Jr. and Robert Ramos.
Please retain the original for your files and return the conformed copies of the claims for Estate of Irene Jaramillo, Isabel Jaramillo, Julian Ramos, Jr. and Robert Ramos to our office in the enclosed self-addressed stamped envelopes.
If you have questions regarding this claim, please do not hesitate to contact our office.
Very Truly Yours,
GASTÉLUM LAW, APC
Denisse O. Dastetum
DENISSE O. GASTÉLUM
Enclosures
3767 WORSHAM AVE., LONG BEACH, CALIFORNIA 90808-1774 | TEL (213) 340-6112 | FAX (213) 402-8622 DGASTELUM@GASTELUMFIRM. COM | WWW.GASTELUMFIRM.COM
CITY OF RIALTO CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
2022 OCT - 3 PM 5:21
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:
Estate of Irene Jaramillo
FULL NAME
DATE OF BIRTH
Bloomington, CA 92316
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808 BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: April 2, 2022 TIME: 1:00
XI AM O 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.
At or near the intersection of Cedar Avenue and Randall Avenue in Rialto, California 92316.
3. HOW DID DAMAGE OR INJURY OCCUR?
The death of Irene Jaramillo occurred during a police pursuit involving Rialto Police Department police officers.
4. WERE POLICE AT THE SCENE? • YES •NO WERE PARAMEDICS AT THE SCENE? DYES •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 death of Irene Jaramillo was caused by the intentional, reckless and/or negligent acts of the Rialto Police Department police officers during a police pursuit which resulted in suspect Alejandro Canchola colliding with the vehicle wherein Irene Jaramillo and Aaron McDonald were passengers.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 20,000,000.00 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: Driver Alejandro Canchola and Passenger Jose Castrocota; contact information unknown.NAME: Unknown Rialto Police Department officers engaged in the ADDRESS: ADDRESs. Pursuit and ensuing investigation.
TELEPHONE: (
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Irene Jaramillo and Aaron McDonald suffered fatal injuries.
NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: |)
DATE: TIME: 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 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.
ERTIFY (OR ) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Were Ve
Denisse O. Gastélum 09/28/22
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 OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 OCT - 3 PM 5:21
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: 150S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Isabel Jaramillo, natural born sister of Irene Jaramillo
FULL NAME
DATE OF BIRTH
Bloomington, CA 92316
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808 (562 ) 203-3030
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: April 2, 2022 TIME: 1:00 * AM • 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.
At or near the intersection of Cedar Avenue and Randall Avenue in Rialto, California 92316.
3. HOW DID DAMAGE OR INJURY OCCUR?
The death of Irene Jaramillo occurred during a police pursuit involving Rialto Police Department police officers.
4. WERE POLICE AT THE SCENE? # YES ONO WERE PARAMEDICS AT THE SCENE? YES ONO
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 death of Irene Jaramillo was caused by the intentional, reckless and/or negligent acts of the Rialto Police Department police officers during a police pursuit which resulted in suspect Alejandro Canchola colliding with the vehicle wherein Irene Jaramillo and Aaron McDonald were passengers.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 20,000,000.00 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: Driver Alejandro Canchola and Passenger Jose Castrocota; contact information unknown. NAME: _ Unknown Rialto Police Department officers engaged in the ADDRESS: ADDRESS ursuit and ensuing investigation.
TELEPHONE: L ) TELEPHONE: _)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: _Irene Jaramillo and Aaron McDonald suffered fatal injuries. NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: ( )
DATE: TIME: DAM 0PM DATE: _ TIME:
• AM O 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 f 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 vehicl 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
7, SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU A RATO RUN THAT HE PORCON THE AND CORNET.
SIGNATURE OF CLAIMANT OR AGENT
Denisse O. Gastélum 09/28/22
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
RIALTO. CANE CITY OF RIALTO
Opi LIABILITY
ORNI
CLAIM FOR DAMAGES 2022 OCT -3 PM 5:21
TO PERSON OR PROPERTY RECEIVED
CITY CLERA
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:
Robert Ramos, natural born brother of Irene Jaramillo
-
FULL NAME DATE OF BIRTH
Bloomington, CA 92316
-
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808 (562 ) 203-3030
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: April 2, 2022 TIME: 1:00 XI AM O 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.
At or near the intersection of Cedar Avenue and Randall Avenue in Rialto, California 92316.
3. HOW DID DAMAGE OR INJURY OCCUR?
The death of Irene Jaramillo occurred during a police pursuit involving Rialto Police Department police officers.
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 death of Irene Jaramillo was caused by the intentional, reckless and/or negligent acts of the Rialto Police Department police officers during a police pursuit which resulted in suspect Alejandro Canchola colliding with the vehicle wherein Irene Jaramillo and Aaron McDonald were passengers.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 20,000,000.00 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: Driver Alejandro Canchola and Passenger Jose Castrocota; contact information unknown.NAME: Unknown Rialto Police Department officers engaged in the ADDRESs Pursuit and ensuing investigation.
TELEPHONE: ) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Irene Jaramillo and Aaron McDonald suffered fatal injuries. NAME:
ADDRESS: _ ADDRESS:
TELEPHONE: ( TELEPHONE: ()
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 THE CLAIMANT.
CURB
SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE BERTI OR PENDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Denisse O. Gastélum 09/28/22
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 OF RIALTO CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY 2022 OCT - 3 PM 5: 21
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:
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:
Julian Ramos, Jr., natural born brother of Irene Jaramillo
FULL NAME DATE OF BIRTH
Bloomington, CA 92316 )
L
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808 (562 ) 203-3030
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Gastelum Law, APC; 3767 Worsham Ave., Long Beach CA 90808
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: April 2, 2022 TIME: 1:00 XI AM OPM
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.
At or near the intersection of Cedar Avenue and Randall Avenue in Rialto, California 92316.
3. HOW DID DAMAGE OR INJURY OCCUR?
The death of Irene Jaramillo occurred during a police pursuit involving Rialto Police Department police officers.
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 death of Irene Jaramillo was caused by the intentional, reckless and/or negligent acts of the Rialto Police Department police officers during a police pursuit which resulted in suspect Alejandro Canchola colliding with the vehicle wherein Irene Jaramillo and Aaron McDonald were passengers.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 20,000,000.00 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: Driver Alejandro Canchola and Passenger Jose Castrocoa: contact information unknown.NAME: _ Unknown Rialto Police Department officers engaged in the ADDRESS: ADDRESs pursuit and ensuing investigation.
TELEPHONE: L TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Irene Jaramillo and Aaron McDonald suffered fatal injuries. NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: | )
DATE: TIME: 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 THE CLAIMANT.
CURB
PARKWAY
SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU LET OR DER PENALTY OF PERRY THAT THE FORECON TUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Denisse O. Gastélum 09/28/22
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 elm Lao APC
7 worsham Are. TY OF RIAL BANGE PAID
7021 0350 0001 1195 202777 - 3 PM AMOUN 22
9 Beach CA 90808 $8.93
RECEIVED 1000 92376 R2305K138961-04
EN RECEIPT CITY CLERK
REALESTED
:LUZ
- L-
2022 OCT - 3 PM RECEIVLU CITY CLERK
Rialto City Cleat's office
150 S. Palm Ave.
Riatto, CA 92376