CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN |/ AMII: 15
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 5911.2).
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:
PATRiCK I SAMPSON TE
-
FULL NAME DATE OF BIRTH
RialtO CA 9237lP
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 1/7/2023 TIME: Le. 000AME/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.
PePPER AUR, FOOtHill BIVD.
3. HOW DID DAMAGE OR INJURY OCCUR?
Iwas Just abalt to go threw a gReen light and Mit
a Pot Hole
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? • YESENO
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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 120.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: JiRe 1|7|23 Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: TiRe 117/23 Amount: $_
Item/Date:
Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $120.00-
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: PSECIOUS SADObRICA NAME: _
ADDRESS: 2913 ~ POPIAR CiR RiGHO ADDRESS:
CA 023700
TELEPHONE: (900 202 - 6e182 TELEPHONE: ( )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:2 x 2023 JAN ADDRESS: CITY OF RIALT
ADDRESS:
TELEPHONE: L TELEPHONE: (
DATE: TIME: DAM PM
DATE: TIME: AM OPM
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. ePPeR
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
PATRICK L SAMPSON TR 1/9/23
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 CALIFOKNIA TB..
510 E FOOTHILL BLVD
RIALTO, CA 92376
S096407009
Cashier: California T
Transaction 200003
Total $120.00
DEBIT CARD SALE $120.00
VISA 8451
Retain this copy for statement
validation
08-Jan-2023 11:37:10A
$120.00 | Method: FMV
PAI RICK SAMPSON
Reference ID: 300800582649
Auth ID: 000084
MID: *****:t**1886
AID: A0000000980840
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2913 W: Poplar Cir. SN BERNARDINO CA 923
Rialto CA 92376 • 10 JAN 2023 PM6 C
CITY OF RIALTO EVER / USA
2023 JAN 11 AMII: 27
RECEIVE
CITY CLERK
Rialto Cry Clerk' office
150S. Palm Ave.
Ralto CA 92376
S2376-648799