CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 MAR 23 PM 2: 08
RECEIVA
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurence (Gov. Code §911.2). CITY CLERE
2. Claims for damages to real property must be filed not later than one (1) year after the occumence (Gov. Code §911.2).
3.READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
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:
Deborah Stone
FULL NAME DATE OF BIRTH
Rialt 92317
HOME ADDRESS INCLUDING CITY, STATE & ZIP -
HOME TELEPHONE NO.
1 nala
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): Same as above
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _ 2/27/2023 TIME: 5:05
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.
Approximately at 759 N. Locust Aul, Xialto 92376
Southbound on Mon. Feb 27th around
Rear passenger tire popped.
the rain where It wasnt ven wellit wahound in the carly Manniegin a ven deep pothole that was not visible to men M Fre
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? • YES DENO repair,
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
cim of Rialto had hot repaired pothole or put cones
up to Keep vehicles from it.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 242.05 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Tire Replacement + Fees 242.05
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 242.05 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, it necessary) NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: | ) TELEPHONE: ( )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: |)
DATE: TIME: _ L AM LI 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.
L L
SOUt
CURB
759 Loust CITY CLERK RECEIYED 221 2 4 2 09 CITY QF RIALTO
PARKWAY
7/F 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. 1 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Deborah Stone 3/22/23
TYPE 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 - 150S. PALM AVE., RIALTO, CA 92376
VIEW SALES INVOICE
AMERICA'S TIRE 2/27/2023
9:44 AM
BRYAN STONE
RIALTO, CA 92377
(M)
2011 LEXUS
IS250C Miles: 153,859
18"OPT. CONVERTBLE Torque Specs: 80
CAL 40 CA# ARD271871
16065 SIERRA LAKES PKWY 1468680 2023 MAR 23 PM 2: 09 CITY OF RIALTO -
FONTANA, CA 92336 CLERX
909.770.5001
Salesperson 6
CORY A A
Estimated Completion Time: 12:02 PM :
Article Qty Description FET Price Amount
89668 2 225 /40 R18 92Y XL BSW 173.00 346.00
NRM CON CONTROL CONTACT SPORT SRS+
TIRE MILEAGE WARRANTY : 50000
BOLT PATTERN: 5-114.3
INFLATION F: 35
2 CERTIFICATES FOR 29.20 58.40
REPLACEMENT
For tire certificate details, see
www.americastire.com/customer-service/certificates
2 STATE REQUIRED 1.75 3.50
2 WASTE TIRE 2.50 5.00
DISPOSAL FEE
80219 2 INSTALLATION & 22.00 44.00
NRM LIFE OF TIRE MAINTENANCE
Terms and Conditions can be found at
www.americastire.com/customer-service/invoice-terms
The tire and/or wheel you have chosen is different
rom the original equipment provided with your
vehicle and may change its handling or stability
characteristics.
information is available from your
America's Tire salesperson.
Sub Total: 156.9
Sales Tax: 27.2
•
Sales Total: 484.11
Tendered: 484.11 (VIS)
Tkn# XXXXXXXX3463 Ath# 027646
Tendered Today: 484.11
Tendered Total: 484.11