CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 MAR 24 PM 12:10
RECEIVED
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 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Derek M. Dorsey
FULL NAME DATE OF BIRTH
Rancho cucamansa, 491730
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 1/16/2023 TIME: 2:00-3:00 MAMOPM
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.
I wAs headed north on s. Riverside Ave it was a rainy night and samewhere between & wilson st. and w. First ST. I had ran over a pothole and tire popped imnediately. I had to pull ava
3. HOW DID DAMAGE OR INJURY OCCUR JUSt aFte passins wa First street and had to call triple Aft, Iran over the pothole of course not knowing it was there It was a rainy night and couldrit see it.
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? •YES ANO
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.
I wa traveling in the city of kialt and had gune iver
a larse pothole. I had to have my car towed to vu
dealership in ontario because tire That polfed had a wheel lock- Ihad
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 403,46 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
TIRe / 1/10/2023 403,46
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 403.46 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: — AAA Towing has The NAME: NORA DISEY
ADDRESS: — incident called in For ADDRESS:
1/10/2023 Rareho cuvanuns a
TELEPHONE: TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: | )
• AM • PM TIME: 2023 03 AM 0 PM
DATE: TIME: DATE:_
TY
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 comers.
If a citytown 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 fime 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
see map
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
Derek Dorsey 3/22/2023
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 - 150 S. PALM AVE., RIALTO, CA 92376 N
W E. FirST street
s. Riverside me happened Between here sumewhere:
ERiaHO Ave.
W. Bonnie view
Dr
E. mEen sT.
Customer Number:856246 | ONTARIO
Invoice No: 246878
*INVOICE* ONTARIO VOLKSWAGEN
701 KETTERING DRIVE
DEREK MATTHEW DORSEY ONTARIO, CA 91761
RANCHO CUCAMONGA, CA 91730 FAX: (909) 605-5804
Home: ONTARIOVW.com
Bus: Cell:
Email: EMAIL BAR: ARD227317 EPA: CAL000269201
HOME SERVICE ADVISOR: 746 JAIME FLORES
STOCK NO. MAKE/MODEL LICENSE MILEAGE IN / OUT TAG
BLACK 19 VOLKSWAGEN ARTEON 39365 / 39365 IT4952
DEL: DATE PROD. DATE WARR EXP. REQUESTED: PO NO. INV. DATE 18MAR22 16JAN23 191.22
CASH 16JAN23
RLO. OPENED READY OPTIONS: SOLD-STK:CV210631A ENG:2.0_Liter_TSI TRN:8_SPEED_AUTOMATIC 12:17 16JAN23 16:42 16JAN23
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A DT1550103 CONTINENTAL LEFT FRONT... (C) CLIENT REQUESTS TO REPLACE 1
TIRE TO INCLUDE MOUNT AND BALANCE
GIT (C) CLIENT REQUESTS TO REPLACE 1 TIRE TO
INCLUDE MOUNT AND BALANCE
740 . CPC 22.00 22.00
1 DT1-550-103 PROCONTACT 275.00 275.00 275.00
1 TIRE TIRE TAX 1:75 11.75 1.75
PARTS: 275.00 LABOR: 22.00 OTHER: TOTAL LINE A: 298.75
39365 GIT 0.40 CUSTOMER STATES REPLACE 1 TIRE LEFT FRONT TIRE,
REMOVED AND REPLACED LEFT FRONT TIRE MOUNT AND BALANCED NEW DOT AFTU WCA3 1822
****************************************************
B: (C) DIAGNOSIS AND REPAIR: CUSTOMER REQUEST REPLACING WHEEL LOCKS
WITH BOLTS AND CAPS
VSC REPLACED WHEEL LOCKS WITH BOLTS AND CAPS AS
PER CUSTOMER REQUEST
740 : CPC 0.00 0.00
4 WHT-001-812 WHEEL BOLT 11.76 11 • 76 47.04
4 1K0-601-173-9B9 CAP 7.59 7.59 30.36
PARTS: 77.40 LABOR: 0.00 OTHER: 0.00 TOTAL LINE B: 77.40 39365 0.25 REMOVED AND REPLACED WHEEL LOCKS TO REGULAR BOLTS AND
PROVIDED NEW CAPS FOR NEW LUGS
*************************
C CHECK TIRE PRESSURES
AIR INSPECT AND ADJUST TIRE PRESSURES TO FACTORY
SPECIFICATION AND PERFORM TREAD WEAR
INSPECTION.
(N/C)
PARTS: 0:00/ LABOR: OTHER: TOTAL LINE C: 0.00
****************************************************
D DURING YOUR VOLKSWAGEN SERVICE TODAY WE WILL BE PERFORMING A COURTESY VEHICLE INSPECTION. (SEE ATTACHED BLANK MULTI-POINT INSPECTION SHEET)
COURTESY DURING YOUR VOLKSWAGEN SERVICE TODAY WE
ORIGINAL ESTIMATE REVISED ESTIMATE
DESCRIPTION TOTALS
We value your privacy. To learn more about our collection and use of your LABOR AMOUNT 1 acknowledge notice and oral approval of an increase in the personal information and your rights, see our Privacy Policy and Notice at PARTS AMOUNT original estimated price. Collection available at www.ontariovolkswagen.com. By signing below,
GAS, OIL, LUBE
CUSTOMER SIGNATURE you acknowledge receipt of this Privacy Notice.
SUBLET AMOUNT
WE FEATURE THE FOLLOWING:
Customer acknowledges and approves all repairs as itemized MISC./HAZ. WASTE CHARGES EXTENDED SERVICE AND PARTS HOURS • LOW COST RENTAL CARS and/or receipt of vehicle. TOTAL CHARGES
QUICK SERVICE WITHOUT APPOINTMENT FOR MINOR REPAIRS
NOTICE TO CONSUMER LESS INS/ADJ
PLEASE READ IMPORTANT INFORMATION ON BACK SELF SERVICE PARTS AND ACCESSORY DEPARTMENT $30.00 SERVICE CHARGE FOR RETURNED CHECKS. SALES TAX
EXPERT CAR POLISHING DEPARTMENT
CUSTOMER SIGNATURE
ALL PARTS INSTALLED ARE NEW UNLESS SPECIFIED PLEASE PAY OTHERWISE. THIS AMOUNT
Customer Copy
ONTARIO
Customer Number:856246 Invoice No: 246878
*INVOICE* ONTARIO VOLKSWAGEN
701 KETTERING DRIVE
DEREK MATTHEW DORSEY ONTARIO, CA 91761
7475 TYLER PL Page 2 of 2 (909) 605-5800
RANCHO CUCAMONGA, CA 91730 FAX: (909) 605-5804
Home: 909-346-7891 Bus: :909-346-7891 Cell: ONTARIOVW.com BAR: ARD227317 EPA: CAL000269201
Email: EMAIL| [email protected] |HOME SERVICE ADVISOR: 746 JAIME FLORES STOCK NO. YEAR MAKE/MODEL LICENSE MILEAGE IN / OUT
TAG
BLACK 19 VOLKSWAGEN ARTEON 39365 / 39365 T4952
DEL: DATE PROD: DATE WARR, EXP REQUESTED PO: NO. INV. DATE 18MAR22 16JAN23
191.22 CASH 16JAN23
R.O. OPENED READY OPTIONS: SOLD-STK:CV210631A ENG:2.0_Liter_TSI TRN:8_SPEED_AUTOMATIC 12:17 16JAN23 16:42 16JAN23
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
WILL BE PERFORMING A COURTESY VEHICLE
INSPECTION. (SEE ATTACHED BLANK MULTI-POINT
INSPECTION SHEET)
740 ISP (N/C)
PARTS: 0.00. LABOR: 0.00 OTHER: 0.00 TOTAL LINE D: 0:00 39365 FRONT TIRES: LEFT 10/32 (NEW) RIGHT 4/32...•. REAR TIRES 6/32 (REPLACE AT 4/32) - FRONT BRAKES 10MM REAR BRAKES 10MM(REPLACE AT 3MM TO 4MM)
***
**** ********* ***** **** *****
ESTIMATE: 386.15 16JAN23 12:17 SA: ..746
CONTACT: DEREK
TIRE AND BOLTS
******************
***• ******** ****
ESTIMATE: 0.00 16 JAN23 12:17 SA: 746
CONTACT
***** ********
SET YOUR SERVICE APPOINTMENT AT YOUR LEISURE
VISIT WWW.ONTARIOVW.COM SELECT SERVICE TAB
THANK YOU FOR CHOOSING ONTARIO VOLKSWAGEN. WE
APPRECJATE YOUR BUSINESS. HAVE A WONDERFUL
DAY. ONTARIO VW SERVICE TEAM
ORIGINAL ESTIMATE REVISED ESTIMATE DESCRIPTION
TOTALS
We value your privacy. To learn more about our collection and use of your LABOR AMOUNT 22.00 1 acknowledge notice and oral approval of an increase in the personal information and your rights, see our Privacy Policy and Notice at PARTS AMOUNT 352.40 original estimated price. Collection available at www.ontariovolkswagen.com. By signing below, GAS, OIL, LUBE 0.00
CUSTOMER SIGNATURE you acknowledge receipt of this Privacy Notice.
SUBLET AMOUNT 0.00
MISC./HAZ. WASTE CHARGES 1.75
Customer acknowledges and approves all repairs as itemized EXTENDED SERVICE AND PARTS HOURS • LOW COST RENTAL CARS and/or receipt of venicie. TOTAL CHARGES 376.15
QUICK SERVICE WITHOUT APPOINTMENT FOR MINOR REPAIRS
NOTICE TO CONSUMER LESS INS/ADJ
PLEASE READ IMPORTANT INFORMATION ON BACK SELF SERVICE PARTS AND ACCESSORY DEPARTMENT 0.00 $30.00 SERVICE CHARGE FOR RETURNED CHECKS. SALES TAX
EXPERT CAR POLISHING DEPARTMENT 27,31
CUSTOMER SIGNATURE
ALL PARTS INSTALLED ARE NEW UNLESS SPECIFIED PLEASE PAY OTHERWISE. THIS AMOUNT $ 403.46
Customer Copy
Copyright 2014 CDX Global, LLC SERVICE INVOICE TYPE 2 - SIC - IMAGING Transaction details
$403.46
Transaction: 01/16/2023
Posted: 01/16/2023 0
Merchant info
ONTARIO, CA
Additional info
Transaction description
ONTARIO VOLKSWAGEN ONTARIO CA
ONTARIO VOLKSWAGEN
TUT S. KETTLING GR
9092319711
Cashier: Michael
Transaction 612288
Invoice Number: 246878
Total SIS 15
CREDIT CARD SALE $-165.46
Retain this copy for statement
validat
16 Jan-2023 5:02.4.T
$403.46 | Method: CONTACTLESS
VISA XXXXXXXXXXX
Reference ID: 301/00/11:26
Auth ID: 0160:4
MID: ********CH*:
AID: A000000003 C11
AthNtwkiNn. VSA
SIGNATURE VERIFIED
Payment OKVAZ4WK00F50
Clover Privacy frie
https://ciover.com/pri70s:
• SANTA ANA CA 926
22 MAR 2023 PM7
Rialto city Clerk's office
150.5. Palm Ave
Rialto, (9 92376
CITY OF RIALTO 2023 MAR 24 PM12:10
142? 45: S2376-848799.