CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN 18 PM 12:15
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).
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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
I gracio Penaloza 8/16/99
-
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE &ZIP Rialto, C1 92376 HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP Attorney steve Wen BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE z25 w. Hospitality Love. # 212
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): SaN Bearin CA 92408
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: — 11/11/2022 _TIME:_ • 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.
Rialto CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Juri penalazes PeNaloza wur hain a reizure and de tamil culled arrel with Ambulane serviver t
they tasered Igrusio Pavaloza carsin, him L be hospitalize
4. WERE POLICE AT THE SCENE? EYES •NO WERE PARAMEDICS AT THE SCENE?
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.
Rinlt police ottiers tarrel somene hivig seizures.
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: puir 11/11/22 - Amount: $
Hem/Date: I- Ffering "/ 11/22 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) Juresh Veralora
NAME: NAME: Cruz Mayoral
ADDRESS: ADDRESS: _
Rialto 92376 Rinlto 92776
TELEPHONE: ( TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Arrawhen Region Madel Celer NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: ( )
DATE: TIME: • AM • 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
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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
IgnaCiu Penalua
SIGNATURE OF CLAIMANT OR AGENT
ISraCt Peratora 1/41/23
TYPE OR PRINT NAME DATE
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
STEVEN WEAVER
Attorney at Law
243000
325 W. Hospitality Lanc, Suite 212 San Bernardino, CA 92408 (909) 571-5599 Steven(@ McGcePL.C.com
LAW OFFICE OF JAMES MCGEE
A PROFESSION. ORPORATION
www.McGeePLC.com