CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN 27 AMII: 36
TO PERSON OR PROPERTY RECEIVED
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:
Gloria Jean Hernandez 01/25/1964
FULL NAME DATE OF BIRTH
2350 Osbun Rd #92, San Bernardino, CA 92404 1909, 284-6849 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 Professional Lawyers Group (909) 885-2922
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 1300 N. Mt. View Ave. San Bernardino, CA 92405
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 07/30/2022 6:30 TIME: • AM NPM
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.
East sidewalk of Yucca Avenue approximately 50 feet south of Woodhill Street.
3. HOW DID DAMAGE OR INJURY OCCUR?
As claimant walked northbound on the east sidewalk, claimant tripped on a raised slab of concrete on the sidewalk. The slab was raised approximately 1-3/4 inches.
4. WERE POLICE AT THE SCENE? •YES IV NO WERE PARAMEDICS AT THE SCENE? DYESIVNO
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.
City failed to maintain sidewalk to be free of hazardous elevation changes in the sidewalk. It appears that an adjacent slab of concrete had been recently poured.
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: Medical Expenses To Date Amount: $_22,869
Item/Date: General Damages Amount: $_100,000
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 122,869 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
tem/Date: Future Medical Expenses Amount: $_100.000
Item/Date: Future General Damages Amount: $250,000
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 350,000
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED: (See Attached) NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: ( ) TELEPHONE: | )
DATE: TIME: • AM • 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. 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 vehicl nen 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
/ N →
WOODHILL ST.
DOnEy oR DECLARE UNDER PENALTY OF REURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF OLAIMANTLOR AGENT
01/25/2023
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, CÁ 92376
Yucca Ave
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Woodhill St & Yucca
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