CITY OF RAL
ITY CLERK'S DATE STAM
CITY OF RIALTO 2023 FEB 16
AM ||: 16
LIABILITY
RECEIVED
CLAIM FOR DAMAGES CITY CLERK
TO PERSON OR PROPERTY
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: 290W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Cruz Mayoral
FULL NAME DATE OF BIRTH
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 Attorney Steven Weaver: 325 W. Hospitality Lane, 212
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): San Bernardino, CA 92408 - Unlimited Civil Case
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 11/11/2022 TIME: 6-12 •AM LIPM
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.
Rialto, CA 92376 - Inside of the residence
3. HOW DID DAMAGE OR INJURY OCCUR?
Ignacio Penaloza was having a seizure and 911 was called. For some reason police were with the paramedics and they tasered the person having a seizure. When the family and Mr. Mayoral was asking why this was happening, police officer assaulted Mr. Mayoral and wrongfully arrested him. He was punched in his groin area.
4. WERE POLICE AT THE SCENE? • YES •NO WERE PARAMEDICS AT THE SCENE? *YES ONO
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.
Cruz Mayoral was bettered in his privates and wrongly arrested. The Oficers name is unt. Flares.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ Unlimited HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Pain, suffering, wrongful arrest: 11/11/2022 Amount: $ Unlimited Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: Unlimited ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: _ Unknown currently Amount: $ Unlimited
Item/Date: Unknown currently Amount: $ Unlimited
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: Unlimited
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) Janeth Penaloza, Concepcion Pudilla + Ignucio PeNalozu
NAME: NAME:
ADDRESS: ADDRESS:
Rialto, CA 92376 Rinto SA 92376
TELEPHONE! TELEPHON
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
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.
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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Steven Weaver 2/13/2023
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, CA 92376