CITY OF RIALTO CITY CLERKSOATE STAMP
LIABILITY OF RIALTO
2023 FEB -6 PM I: 33
CLAIM FOR DAMAGES
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 69112).
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: 150S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
ennis ELLiot WAtLANd
FULL NAME DATE OF BIRTH
ave Bloomington ca.92316 1 1
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: - 8-28-30-22 TIME:— 11:05 AAMOPM
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.
MA
3. HOW DID DAMAGE OR INJURY OCCUR?
It occured 8-30-2022. When my Convette was cited
With a 72 hour to move Vehicle Notice, ANd Was Impounded BeFore The 72 houn deadline.
4. WERE POLICE AT THE SCENE? DYES D NO WERE PARAMEDICS AT THE SCENE? • YES LNO
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.
Vehicle be Fone Th 72 hours, alsa no Recond
of my signed off ticket. Which caused me to Lase my corvette.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 9,900.
HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: 2-6-22 Edmunds Amounts 4, 719/7320.
Item/Date: 26-22, Kelly • Sue Sark Amount: $7,300."-12,300.0.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 59,900.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Convette 2-6-2023
Amount: $ 9,400. 00
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 9,400.
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Ralto Police dept NAME: RePes Towing Scavice
ADDRESS: 128 N Willow que ADDRESS: 2775 N Locust ave
Rialto ca 42376 M'alto Ca 92377
TELEPHONE: 468 82- 2550 TELEPHONE: 904 574/490
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: TELEPHONE: | )
DATE: TIME: L AM PM DATE:
TIME: DAM Q 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 comers.
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
/ 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.
ICERTIEY (OR DECLARE) UNDERPENALFY OF PERJURY JHAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
DeNNiS WAtLANd 2-6-2025
TYPE OR PRINT NAME DATE
Self
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