CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN ~9 AMII: 38
TO PERSON OR PROPERTY
RECEIVEL
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: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Jonathan Basurto
-
FULL NAME DATE OF BIRTH
Fontana, CA 92337
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. -
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE 1651 E. Fourth Street, Suite 123, Santa Ana, CA 92701
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 09/03/2022 TIME: 1:45 XAM • 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.
Cactus Avenue and Lilac Avenue in the city of Rialto, California.
3. HOW DID DAMAGE OR INJURY OCCUR?
Mr. Basurto was arrested and handcuffed, cuffs were too tight which caused injuries to his hands, left wrist median nerve injury, numbness and swelling.
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.
Officer Burk and another officer whose name is unknown, employed by the police department for the city of Rialto. Placed handcuffs on Claimant that were too tight and caused injuries to his hands and left wrist median nerve injury
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_Excess of $25.000.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Treatment is still ongoing Amount: $ Pending Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: $ Excess of $25,000.00 Item/Date: Claimant's medical treatment is still ongoing, general damages Amount: $
Item/Date: for pain and suffering is unknow at this time but damages should beamount: $ TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: within the unlimited jurisdiction of the California Superior Court $ Unknown at this time
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Mario Ochoa
NAME:
ADDRESS: Unknown
ADDRESS:
TELEPHONE: | ) Unknown
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: Kaiser Permanente
NAME: _
ADDRESS: 9961 Sierra Avenue
ADDRESS:
Fontana, CA 92335
TELEPHONE: (833) 574-2273 TELEPHONE: L
DATE: 09/09/2022 TIME:
• AM OPM 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.
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 TRUI ICERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANTOR AGENT
Michael F. Smith 1-0-2023
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 LAW OFFICE ITA A!:
MICHAEL FRANCIS SMITH
165 1 EAST FOURTH STREET, SUITE #123 :2023
SANTA ANA, CALIFORNIA 92701
7021 1970 0000 2214 1902
Rialto City Clerck's Office
150 S. La Palm Avenue
Rialto, CA 92376
9126d6H56Z0Z
92376-6765E