CITY OF RIALTO CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
2023 MAR -3 AMII: 19
CLAIM FOR DAMAGES
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 59112).
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:
Wendy Awarez
FULL NAME DATE ÖF BIRTH
Rialto 0A92516
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 Lame as aDove
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 11-1-2022 _ TIME: 5:30-10:00 AMYRPM
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. down riverside Ave going soutr
Iwas drivinglarket, winer I turn into the sata. to Superior Joutn entrance of superor market there was
3. HOW DID DAMAGE OR INJURY OCCUR? Uneven pavement and cim got scratch board
uneven pavement.
4. WERE POLICE AT THE SCENE? • YES GENO WERE PARAMEDICS AT THE SCENE? YESTONO
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.
Uneven pavement
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1313.85 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 11-1-2022 Amount: $ 1313.85
Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1313.85 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Cynthia ToM outreach wisgroup
ADDRESS:
TELEPHONE: TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A
ADDRESS: ADDRESS:
TELEPHONE: ( ) TELEPHONE: ()
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 accident by "B-1" and the point of impact by "X".
A. Rialito
• NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIONED BY THE CLAIMANT. ine Ave
B
CURB ging southeride rie
PARKWAY
7/. SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO HOSE 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.
Wendu Alvarez
SIGNATURE OF CLAIMANT OR AGENT
venu Alvarez / 2023
YPE 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
AUTO GALLERY MITSUBISHI CORONA
2550 Wardlow Road - Corona, CA 92882
(951) 372-0008 - Fax: (951) 372-9373
MITSUBISHI www.AutoGalleryMitsubishi.com
MOTORS
SOLD TO
DELIVER TO
ALVAREZ. WENDY
RIALTO, CA 92376
RETURN POLICY: No returns or cancelations on electrical. body, safety, or special order items. All claims and retumed goods must be accompanied by this invoice A minimum 35% restocking charge will be applied on all merchandise returned for credit. No retums after 30 days.
DISCLAIMER OF WARRANTIES: All
either expressed or implied, including any implied warranty of merchantability or fitness for a particular purpose, and AUTO GALLERY MITSUBISHI CORONA, neither assumes nor authorizes any other person to warranties on the products sold hereby are those made by the manufacturer. The seller. AUTO GALLERY MITSUBISHI CORONA, hereby expressly disclaims all warranties. assume for it any liability in connection with the sale of said products. Any limitation contained herein does not apply where prohibited by law.
YOUR PURCHASE ORDER TERMS
INVOICE DATE INVOICE NUMBER / PG.
Payment Due Upon Receipt 12/03/22 0000099477
SHIP VIA 1
SALESPERSONS NAME
Will Call
Timothy Bayouth
QTY. DESCRIPTION
SOURCE LIST
NET AMOUNT
4250G022 : WHEEL, DISC SPORD 1208.14
Installation - sinn no 1208.14 1208.14
*********************************
* DAMAGE / SHORTAGE MUST BE *
* NOTED AT TIME OF DELIVERY. *
* NO EXCEPTIONS. *
******************* *****
DATE PRINTED 12/03/22 TIME 11:21:48 SERVICES OR EQUIPMENT 1208.14
PARTS DEPARTMENT HOURS SHIPPING
C.O.D. CHARGE
8:00 a.m. to 5:00 p.m. Mon - Sat
SALES TAX OR TAXI.D. 105.71
DEPOSIT ON CONTRACT
TOTAL 1313.85
Thank You!
NO RETURN OR CANCELLATION ON ELECTRICAL, BODY, SAFETY, OR SPECIAL ORDER ITEMS X