CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 FEB -2 AMII: 25
TO PERSON OR PROPERTY
RECEIYED
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 5911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2).
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:
Enka Serruno Cror
FULL NAME DATE OF BIRTH -
Rialto CA 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 Riverside CH 92374
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Riverside dA 92376
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 1/9/2023 _TIME: 8:02 DAM DAM
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.
I was driving gang Noah un Pepper when I ran over
a pothole.
3. HOW DID DAMAGE OR INJURY OCCUR?
Please See Attiched
4. WERE POLICE AT THE SCENE? • YES/NO WERE PARAMEDICS AT THE SCENE? DYESNO
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.
A pothole in the middle of the road
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 579.11 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Tires 01/10/2023 324.11
Amount: $
Item/Date: Alignment 01/210| 2023 Amount: $ 55.00
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 579,11 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:Tires 01/10/2023 524.11
Amount: $.
Item/Date: Alignment 01/26/2023 Amount: $_ 55.00
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $579.11
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach aditional pages, if necessary N/ A NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED: N/A NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: TELEPHONE:)
DATE: _ TIME: LAM • 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 x →
Paper
PARKWAY
SIDEWALK
Is
E
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 6 ( CERTIFT OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Erika serrano 01/30/23
TYPE OR PRINT NAME DATE
Selt
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 January 30, 2023
3. On January 10, 2023, at approximately 08:02 pm, I was driving on Pepper Ave., heading north bound when I ran over a pothole. It was rainy and dark outside. The pothole had an impact on the tire, causing the tire to pop, scratched the rim and bent the suspension component out of alignment. When I took it to Costco, Costco recommended I replace both front tires since both tires must wear evenly which will help avoid long term/permanent damage. Costco also recommended an alignment since the suspension was bent from the impact.