CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 2023 MAR 20 PM |: 10
RECLITED
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@I Y 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 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Anessa Raylene Medina
-
FULL NAME T
DATE OF BIRTH
San Bernardino
HOME ADDRESS INCLUDING CITY, STATE & ZIP CA 924I0 HOME TELEPHONE NO.
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 02/08/2023 TIME: 10:00 KAM DPM 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. alto cAt cross streets Baskeline and cans
3. HOW DID DAMAGE OR INJURY OCCUR?
4. WERE POLICE AT THE SCENE? • YES • NO WERE PARAMEDICS AT THE SCENE? DYES ONe tak aff an 5, WHAT PARTICULAR ACT OR OMISSION DO YOU GLAIN CAUSED THE INJURY OR DAMAGES? Give the name of the citytown He was Forgetful and didnt even recall place
he Phen it searched his entire vehick before
returing back to the place I was pulled our.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 450 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: The Entire phone Needs to be Amount: $_ 400
Item/Date: replaced Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
$
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: |
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: L)
TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
TELEPHONE: L)
DATE: TIME:
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
PARKWAY
7 SIDEWALK
¡ HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREO; 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 dE CLAIMANT OR AGENT
Anessa R molina 3/14/2023
TYPE OR PRINT NAME
DATE
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - S. PALM AVE., RIALTO, CA 92376
Sais, Irene
From: Anessa Medina <
Sent: Friday, March 10, 2023 9:53 AM
To: Sais, Irene
Subject: (EXTERNAL]
CAUTION: This message originated from outside the LLUH email system. Do not open attachments or follow links unless you have verified the legitimacy of the sender and its content. If you receive a suspicious email, you may forward it to EmailAbuse @llu.edu and then delete the suspicious email.
OOO IN
Sent from my iPhone
Sais, Irene
From: Anessa Medina <
Sent: Friday, March 10, 2023 10:42 AM
To: Sais, Irene
Subject: (EXTERNAL]
CAUTION: This message originated from outside the LLUH email system. Do not open attachments or follow links unless you have verified the legitimacy of the sender and its content. If you receive a suspicious email, you may forward it to [email protected] and then delete the suspicious email.
Sent from my iPhone
GENIUS BAR
Please retain this document for your records.
Ca BEAR #E81411
Apple Victoria Gardens
Mar 19, 2023 Tel: 909-945-5395
Genius Bar Work Authorization
Repair No: R575740319
Customer Information
Product Information
Anessa Medina Warranty Status: Out of Warranty
United States
(OW)
Model: iPhone 11
Date of Purchase: Jul 5, 2020
Serial No : DNPCT4DTN72K
Problem Description/Diagnosis
issue:
Customer states that the display has multiple cracks.
Customer states multi touch is too sensitive.
Steps to Reproduce:
Verified the issue
Ran SNR
Cosmetic Condition:
Cosmetic Condition: Display - multiple cracks Rear Enclosure - No damage observed Front Camera- No damage observed ear Camera - No damage observed Volume Up - responsive Volume Down - responsive Ring/silent - responsive Side button - esponsive Port - No damage observed Security Screws - No tampering indicated Liquid Contact Indicator - Not tripped Proposed Resolution:
Replace the display at the out of warranty cost of 199 plus tax.
Customer is aware that during the repair if any liquid, 3rd party parts or physical damage is found, the repair cannot be done and the device will have to swap out for a new full unit device at the out of warranty cost.
Customer is aware we are not responsible for any data loss.
Customer is aware photo Id is needed for time of pickup If repair is not successful offer full unit replacement at the out of warranty cost of 399 plus tax.
Resolution: Service Referral
Reason: Other
Repair Estimate
Item Number Description Price
Amount Due Customer
KBB
$
Total (Tax not included) $ 0.00 $ 0.00
The above estimate does not include applicable taxes. Taxes will be calculated at the time of payment.
By signing below, I agree that:
• the Repair Terms and Conditions on the reverse side of this page will apply to the service of the product identified above; • as unintentional loss of data may occur as a result of the service it is my responsibility to make a backup copy of my data before bringing my product to Apple for service;
• Apple is not responsible for any loss or corruption of the data on my product during service; and •Apple may use parts or products that are new or equivalent to new in reliability and performance.
AnessaR. Medina
Customer Name Received By:
Signature: Date:
Important! See Terms and Conditions on the back.
800-APL-CARE, www.apple.com/support
o208 Apple Inc. All rights reserved. Apple and the Apple logo are trademarks of Apple Inc., registered in the US. and other countries. AppleCare and Genius Bar are service marks of Apple Ine. registered in th he US. and other countries