CITY OF RIALTO CITY CLERK'S DATE STAMP
Offi LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN |1 AMII: 16
TO PERSON OR PROPERTY
RECEIVEL
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 5911.2).
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:
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:
PATRiCK I SAMPSON JR
FULL NAME DATE OF BIRTH
Rialto, 0A 92376
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 RialTo CA
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 92374
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 1| le/2023 TIME: 4:30 0AMOPM
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 and mill St Just Before the stop 15ght
3. HOW DID DAMAGE OR INJURY OCCUR?
Was DRiving Down PeppeR Are Right BefoRe MillSt and I Hit a POT HOle , Z
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.
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: TiRe 1/6/2023 Amount: $_ 116.47
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: TiRe 1/10/2023 Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 1|6.47
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
ADDRESS: Rialto ADDRESS:
LA 92374
TELEPHONE: TELEPHONE: (L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED: * 2023 JAN 1/ CITY OF -
ADDRESS: _
RIAL
TELEPHONE: _ TELEPHONE:)
MH
DATE: TIME: DAM •PM DATE: TIME: SAM DIPM
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.
LODER AN
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. ^ ..
SIGNATURE OF CLAIMANT OR AGENT
PATRiUK L SAMPSON JR 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
AMERICAN FIND STORE HOURS
AND LOCATIONS ONLINE
TIRE DEPOT AMERIGANTIREDEPOT.COM
Started Time: 1/6/2023 5:25:15 PM
A BIBRAND TIRE & SERVICE COMPANY Invoiced Time: 1/6/2023 5:46:39 PM Invoice#: 1163-2650616
CUSTOMER INFORMATION VEHICLE INFORMATION STORE LOCATION SAMP SON, PAT Cust #: ED-4775838 2021 HONDA CIVIC LX RIALTO #1163 BAR# ard301169 Engine: L4-122Cl 1996CC 2.0L 185 E. FOOTHILL BLVD EPA#:CAL000470360 RIALTO, CA 92376 RIALTO. CA 92376
Phone: L Phone: (909) 279-1567
Emails: Vehicle Service Emails Inactive Started By: JA408 Invoiced By: JOSUE ALVAR (JA408)
BRAND PART DESCRIPTION TECH SALESPERS PRICE OTY
TOTAL
IRI 613354400760 @225/40R18XL SEAR 92W XL IRI - JA408
JC331 $77.99 1.0000 $77.99
Tire Serial# 033MDKOO 192
Minimum Mileage Warranty: 50000
********** CONSUMER ADVISORY**** ****** THIS IS A "W" RATED TIRE. IT HAS A MAXINUM SPEED OF 168 MPH. IT HAS "W" HANDLING CHARACTERISTICS. CONSULT YOUR OWNERS MANUAL FOR THE PROPER SPEED RATING RECOMMENDED FOR YOUR VEHICLE. CUSTOMERS
INITIALS
CDF CDF TIRE RECYCLING JC331 JA408 $4.50 1.0000 $4.50
LBR WBHS HIGH SPEED WHEEL BALANCE JC331 JA408 1.0000
$20.99 $20.99
SHP wW LEAD FREE WHEEL WEIGHTS - PARTS JC331 JA408 $4.50 10000 $4.50
STF STF CALIF. STATE TIRE FEE JC331 JA408 $1.75 $1.75
1.0000
I have been informed of the benefits of BBT's Tire Maintenance Certificate progrem. ALL-WHEEL DRIVE VEHICLE NOTICE - Most manufacturers recommend the rolling radius of all 4 tires must be the same. Tires should be replaced in sets of 4 to match brand, size, design and tread depth Please consul your owners manual for the Original Equipment Vehicle Manufacturers recommendations. TWO TIRE PURCHASE ONLY - SAFETY ADVISORY - The Tire Association Council states that if only two new tires are installed on the front of a vehicle, the rear wom tires could loose their grip under load or slippery conditions causing loss of control.
LBR DEW CUST DECLINED TIRE MAINT CERT. JC331 JA408 $0.00 1.0000 $0.00 EXTENDED WARRANTY OFFER HAS BEEN DECLINED. EW PRICE OFFER IS VALID FOR 30 DAYS AFTER INVOICE DATE.
LBR UCI CUSTOMER DECLINED ROADHAZARD WARRANTY JC331 JA408 $0.00 1.0000 $0.00 Vehicle Tire Pressure - F:32 R: 32
- Invoiced Summary
Revisions Payment Invoice Totals
Date Employee Previous Revised Type Auth Email/ Phone# Type Amount Parts: $86.99 CCD2 116.47 FET: $0.00
1947767536
PATRICK SAMPSON Shop Fees: $0.00
Debit 8451
NonTax: $22.74
Tax: $6.74
Pang
I acknowledge below and receipt of this invoice
Total: $116.47
This estimate is based on our inspection at this time and does not cover additional parts and labor which may be required after the work has been started. Afler the work has started, worn or damaged parts which are not evident on first inspection may be discovered. This estimate cannot cover such contingencies. In cases where additional work is deemed necessary, customer authorization will be secured prior to commencement of that additional work. This estimate expires 15 days from date. I hereby authorize the repair work to be done along with the necessary material and hereby grant you and or your employees permission to operate the vehicle herein described on the streets, highways or elsewhere for the purpose oftesting and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto.
Dealer not responsible for unavailability of parts or delays in parts shipments beyond dealers control not for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond our control.
Additional terms notice and oral approval of an increase in the original estimated price. See website for warranty details.
Customer Initials:
AMERICAN FIND STORE HOURS
AND LOCATIONS ONLINE
TIRE DEPOT AMERIGANTIREDEPOT.COM
Started Time: 1/6/2023 5:25:15 PM
A BICBRAND TIRE & SERVICE COMPANY Invoiced Time: 1/6/2023 5:46:39 PM Invoice#: 1163-2650616
CUSTOMER INFORMATION VEHICLE INFORMATION STORE LOCATION SAMPSON, PAT Cust #: ED-4775838 2021 HONDA CIVIC LX RIALTO #1163 BAR#:ard301169
Engine: L4-122Cl 1996CC 2.0L 185 E. FOOTHILL BLVD EPA#:CAL000470360 RIALTO, CA 92376 RIALTO, CA 92376
Phone: I Phone: (909) 279-1567
Emails: Vehicle Service Emails Inactive Started By: JA408 Invoiced By: JOSUE ALVAR (JA408)
CITY CLERA RECEIVLI 2023 JAN 11 AMII: 16 CITY OF RIALTO
2913.M Poplar Cir: SN BERNARDINO CA 923
Kialto CA 92376. 10 JAN 2023 PM7 L
CITY OF RIALTO
2023 JAN 1| AMII: 27
RECEIVEL
CITY CLER*
Riato city Clerk's
Office
150 S. Palm Ave:
Rialto CA 92376
92376-646799