CITY OF RIALTO CITY CLERK'S DATE STAMP
SANTO, CLEAT
LIABILITY
RNA CITY OF RIALTO
CLAIM FOR DAMAGES 2022 OCT - 7 AMH: 25
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:
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Report # 932211818 Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Pricillo Nunet
FULL NAME DATE OF BIRTH
Cotton CA 92324
HOME ADDRESS INCLUDING CITY, STATE & ZIP apt 2114 HOME TELEPHONE 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: 10/02/2022 • TIME: 7:00 •AMP
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. stapliaht on first street and Riverside ave Rialto cA
3. HOW DID DAMAGE OR INJURY OCCUR?
- was at a stop light Stopped and Dolice car came on the left side of me and side swiped my car hitting mu drivers mirrar. He left the scene came back ater I called al
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? YES ENO
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 Wasnit given anu information on the person who hit me.
It was a Rialto police officer in an
Report# 932211818
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 781.62 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: left mirror hausing 781.62
Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Item/Date: Amount: $.
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: (
TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
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.
VersacuRE ave
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 GERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Pricilla Nunez
TYPE OR PRINT NAME 10/5/22
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) @ First St
this is the only info
I got on the officer
Who hit me.
CITY CLERK RECEIVED 2022 OCT - 7 AMII: 25 CITY OF RIALTO Tried to take Photo.
Of before he drove
away.
=
CITY CLERK RECEIVED 2022 OCT -7 AMII: 25
CITY OF RIALTO
2022 OCT - 7 AMII: 25
RECEIVED
CITY CLERK
CITY OF RIALTO CITY OF RIALTO
2022 OCT - 7 AMII: 25
RECEIVED
CITY CLERK
CELL:
208992 BERNIE CASH TJ WHITE 10/06/22 PQ374473
CVR
VIN
DE LOS RIOS MONIC 661155
FONTANA, CA 92336
1 0 84626244 MIRROR 10.185 TEST 408.00 408.00 408.00
LABOR 8342-
CITY CLERK RECEIVED 2022 OCT - 7 AMI: 25 CITY OF RIALTO 408.00
RESTOCK CHARGE 0.00
TAX 31.62
FREIGHT 0.00
439.62
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