CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 FEB 24 AMII: 23
RECEIVEL
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). CITY CLERK
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 9237
ddress: 290 W. Rialto Ave., Rialto, CA 9237
CLAIMANT INFORMATION:
LELIA D. ROBERTSON
FULL NAME DATE OF BIRTH
RIALTO, CA 92376
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 150 SOUTH PALM AVENUE, RIALTO, CA 92376
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: NOVEMBER 15, 2022 TIME: 4:00 • AM IX PM
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.
CITY OF RIALTO, 150 SOUTH PALM AVENUE, RIALTO, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
The City Manager made a determination that a personnel calculation error made regarding in-lieu health as set forth below.
4. WERE POLICE AT THE SCENE? • YES [NO WERE PARAMEDICS AT THE SCENE? • YES IANO
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.
The City Manager made a determination that a personnel calculation error made regarding in-lieu health CaPERS reimbursement, wherein the City should have provided a 401A instead of the City Human Resources department putting the money into a 457. The City elected to not give the Mayor access.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 132,446.62 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 2003 through 2016 Amount: $ 132,446.62
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 132,446.62 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Increased Tax Liability at 18% See attached Amount: $ unknown Item/Date: consulting fees, attorney fees, costs Amount: $ unknown TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $350,000.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: KURT WILSON - former City Council SEE ATTACHED
NAME:
ADDRESS: ADDRESS:
RIALTO, CA 92376
TELEPHONE: L TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: L
DATE: TIME: • AM • PM DATE: TIME:
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 CITY CLERK RECEIVED 2023 FEB 24 AMI: 23 CITY OF RIALTO
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 CERTIFYJOR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OF AGENT
MICHELLE D. STRICKLAND 2/17/2023
TYPE OR PRINT NAME DATE
ATTORNEY FOR LELIA D. ROBERTSON
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