CITY CLERK'S DATE STAMP
CITY OF RIALTO
Y OF LIABILITY
CLAIM FOR DAMAGES
CITY OF RIALTO
TO PERSON OR PROPERTY
2023 MAR 29 PM 12: 24
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 §9112) RECEIVEL
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2). REFURNT&LERK
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:
Lonath Garcia
1 an
FULL NAME DATE OF BIRTH
San Bernardine / CA/22410
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: |2-20-22 TIME: 7:38
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.
The accident occur inside Rialto Marketplace off Riverside Ave.
It took ploce inside the parking structure. Motorcugale was Stationed in a parking Spot
3. HOW DID DAMAGE OR INJURY OCCUR?
A Police cruirer was reversing parking into the parking spot where the Motoracle was stationed.
4. WERE POLICE AT THE SCENE? YES •NO WERE PARAMEDICS AT THE SCENE? • YES NO
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 officer that was at fault is MR. Rodriquez Badge #02511
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2,281.13 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Supplement of Record (Allstate) 03/8/23 Amount: $ 1,5/2.71 Item/Date: HYR Service (Dealership) 03/18/23 Amount: $1,563.75 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 2,201. 13 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: N/A NAME:
ADDRESS: ADDRESS: _
TELEPHONE: ) TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
N/A
ADDRESS: ADDRESS: _
TELEPHONE: | ) TELEPHONE: )
DATE: TIME: • AM L 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.
CURB
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.
LOERTIEY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
anathan Garcia 03/28/23
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 - 150 S. PALM AVE., RIALTO, CA 92376
CITY OF RIALTO
2023 MAR 29 PM 12:24
RECEIVEL
CITY CLERK
ALLSTATE INSURANCE COMPANY
Allstate Insurance Compan
CALIFORNIA
For Self Service Customer Inquiries:
www.allstate.com/claims/track-claim.aspx
Mailing Address:
P.O. Box 660636
Claim #: 000696437250D01
Dallas, TX 75266 Workfile ID: cb861821
Supplement of Record 1 Summary
Written By: MARK ELLIOTT, 3/8/2023 10:38:37 AM
Adjuster: License: James Teeters, (888) 706-3686 Business Insured: JONATHAN GARCIA Owner Policy #: 000999578140 Claim #: 000696437250D01 Type of Loss: Collision Date of Loss: 12/20/2022 07:38 PM Days to Repair: 1 Point of Impact: 12 Left & Right Side Deductible: 500.00 Owner (Insured): Inspection Location: Appraiser Information: Repair Facility:
JONATHAN GARCIA Desk (661) 549-2695 Owners Choice
SAN BERNARDINO, CA
92410-1301
Cellular
VEHICLE
2022 HOND CMX500LH CRUISER teal
VIN: Production Date: Interior Color:
License: Odometer: 8665 Exterior Color: teal
State: CA Condition: Good
3/8/2023 10:38:37 AM 112780 | 1.9.01.09190 Page 1
Claim #: 000696437250D01
Workfile ID: cb861821
Supplement of Record 1 Summary
2022 HOND CMX500LH CRUISER teal
Line Oper Description Part Number Qty Extended Labor Paint Price $
1 # Use Virtual Assist App for 1 0.00 0.0 0.0
Supplements in app store or
2 # Supplement request at 1 0.00 0.0 0.0
https://allsupplements.allstate.co
m/#/
0.00 0.0 0.0
# S01 Repl TANK SET, FUEL (TYPE1) (WL) 17520-MKG-LAOZB 1 395.33 Incl. M 0.0 # S01 Repl RUBBER, GEARSHIFT PEDAL 24781-KR3-770 3.36 Incl. M 0.0 # S01 Repl BAR, SIDE STAND 50530-K87-A00 18.00 Incl. M 0.0 # S01 Repl SPRING, SIDE STAND 50541-MB0-000 9.99 Incl. M 0.0 # S01 Repl SUB-SPRING, SIDE STAND 50542-MB0-611 2 15.98 Incl. M 0.0 9 # S01 Repl GRIP, L. HANDLE 53165-K87-A00 4.29 0.0
Incl. M
10 # S01 Repl LEVER, L. HANDLE 53178-K87-A30 21.62 Incl. M 0.0 11 # S01 BRKT, HANDLE LEVER 28.98 0.0 0.0
12 # S01 FENDER, FRT 35.02 0.0 0.0
13 S01 BRACE, FENDER FRT 28.84 0.0 0.0
14 S01 BOLT 1 3.07 0.0 0.0
15 S01 BOLT, FLANGE 8X40 1 2.99 0.0 0.0
16 S01 BOLT, FLANGE 8X50 2.99 0.0 0.0
17 S01 NUT, SIDE STAND 1.40 0.0 0.0
18 # S01 NUT, FLANGE 8MM 1.99 0.0 0.0
19 # S01 WASHER, PLAIN 8MM 0.96 0.0 0.0
20 # S01 Subl MOTORCYCLE DEALER LABOR 893.35 X 0.0 0.0
AND MATERIALS
SUBTOTALS 1,468.16 0.0 0.0
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 574.81
Miscellaneous 893.35
Subtotal 1,468.16
Sales Tax $ 574.81 6.0000 % 34.49
County Tax $ 574.81 @ 1.7500% 10.06
Total Cost of Repairs 1,512.71
Deductible 500.00
Total Adjustments 500.00
Net Cost of Repairs 1,012.71
3/8/2023 10:38:37 AM 112780 | 1.9.01.09190 Page 2
Claim #: 000696437250D01
Workfile ID: cb861821
Supplement of Record 1 Summary
2022 HOND CMX500LH CRUISER teal
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Changed Items
4 # Repl TANK SET, FUEL (TYPE1) (WL) 17520-MKG-LAOZB -395.33 -0.8 M 0.0 4 # S01 Repl TANK SET, FUEL (TYPE1) (WL) 17520-MKG-LAOZB 395.33 Incl. M 0.0 # Repl RUBBER, GEARSHIFT PEDAL 24781-KR3-770 -3.36 -0.1 M 0.0 # S01 Repl RUBBER, GEARSHIFT PEDAL 24781-KR3-770 3.36 Incl. M 0.0 9 # Repl BAR, SIDE STAND 50530-K87-A00 -18.00 -0.3 M 0.0 6 # S01 Repl BAR, SIDE STAND 50530-K87-A00 1 18.00 Incl. M 0.0 10 # Repl SPRING, SIDE STAND 50541-MB0-000 1 -8.80 Incl. M 0.0 7 # S01 Repl SPRING, SIDE STAND 50541-MB0-000 1 9.99 Incl. M 0.0 11 # Repl SUB-SPRING, SIDE STAND 50542-MB0-611 -6.56 Incl. M 0.0 8 # S01 Repl SUB-SPRING, SIDE STAND 50542-MB0-611 2 15.98 Incl. M 0.0 14 # Repl GRIP, L. HANDLE 53165-K87-A00 1 -4.29 -0.1 M 0.0 9 # S01 Repl GRIP, L. HANDLE 53165-K87-A00 4.29 Incl. M 0.0 15 # Repl LEVER, L. HANDLE 53178-K87-A30 -21.62 -0.1 M 0.0 10 # S01 Repl LEVER, L. HANDLE 53178-K87-A30 21.62 Incl. M 0.0 Deleted Items
# Repl GASKET, BASE 17574-KZZ-910 -33.05 0.0 0.0
# Repl PEDAL, GEARSHIFT 24720-MKG-A00 -43.84 -0.3 M 0.0 8 # Repl SWITCH ASSY., SIDE STAND 35700-MKG-A01 -51.80 -0.5 M 0.0 12 # Repl STEP, L. 50642-K87-A30 -10.40 -0.3 M 0.0
13 # Repl RUBBER, STEP 50661-K87-A00 -3.82 -0.1 M 0.0
Added Items
11 # S01 BRKT, HANDLE LEVER 28.98 0.0 0.0
12 # S01 FENDER, FRT 35.02 0.0 0.0
13 # S01 BRACE, FENDER FRT 28.84 0.0 0.0
14 # S01 BOLT 3.07 0.0 0.0
15 # S01 BOLT, FLANGE 8X40 1 2.99 0.0 0.0
16 # S01 BOLT, FLANGE 8X50 1 2.99 0.0 0.0
17 # S01 NUT, SIDE STAND 1.40 0.0 0.0
18 # S01 NUT, FLANGE 8MM 1.99 0.0 0.0
19 # S01 WASHER, PLAIN 8MM 0.96 0.0 0.0
20 # S01 Subl MOTORCYCLE DEALER LABOR 1 893.35 X 0.0 0.0
AND MATERIALS
SUBTOTALS 867.29 -2.6 0.0
3/8/2023 10:38:37 AM 112780 | 1.9.01.09190 Page 3
Claim #: 000696437250D01
Workfile ID: cb861821
Supplement of Record 1 Summary
2022 HOND CMX500LH CRUISER teal
TOTALS SUMMARY
Category Basis Rate Cost $
Parts -26.06
Mechanical Labor -2.6 hrs @ $ 120.00 /hr -312.00
Miscellaneous 893.35
Subtotal 555.29
Sales Tax $-26.06 @ 6.0000% -1.56
County Tax $-26.06 @ 1.7500% -0.46
Total Supplement Amount 553.27
NET COST OF SUPPLEMENT 553.27
CUMULATIVE EFFECTS OF SUPPLEMENTS)
Estimate 959.44 JAMES TEETERS
Supplement S01 553.27 MARK ELLIOTT
Workfile Total: $ 1,512.71
TOTAL ADJUSTMENTS: $ 500.00
NET COST OF REPAIRS: 1,012.71
SUPPLEMENT PROCESS INSTRUCTIONS:
Please be aware that any additional damage must be inspected by an Allstate technician while the vehicle is at the shop and torn down (when reasonably appropriate), prior to the repairs being completed. If Allstate is not informed of supplemental damage, it may not be covered under the claim. In addition, all invoices will be requested and reviewed.
For repair shops using CCC One Estimating, supplement requests can be submitted using Estimate Share. The claim number and work file Id located at the top of this document will be needed to proceed. Instructions for using Estimate Share can be found at
https://help.cccis.com/static/ccc_one/training/EstimateShare/RequestingEstimateShareStaffRF.pdf For all other repair shops, please follow the Virtual Assist App process for future supplement requests. The Virtual Assist App can be downloaded at no charge by visiting the Apple App store or the Google Play store. Search, download and install: Virtual Assist Allstate Insurance Co Current Version: CALIFORNIA Updated 01.06.23
3/8/2023 10:38:37 AM 112780 | 1.9.01.09190 Page 4
Printed On : 03/18/2023 3:31:10 PM ( Serv. Writer:PGN - Contact ID :35476 ) Status : Processed Invoice # : 245777
Honda Yamaha Husqvarna of
Type : Service Processed: 03/18/2023
Redlands
215 E Redlands Blvd Completed : 03/18/2023
REDLANDS, CA 92373 Contact ID :39947
Main: 909-793-2833
Fax: 909-793-2474
JONATHAN GARCIA
SAN BERNARDINO, California 92410
UNITED STATES
Mobile
Units for Service
Year Make Model Name (#) VIN/Serial Color Description
2022 HONDA (CMX500) GRN
Unit Type Engine Model Engine Serial Engine Type SKU/Stock # License # Motorcycle
Odometer In Odometer Out Hours in Hours Out
8696.00 8696.00 0.00
Job Title : DAMAGE REPAIR PARTS LIST - Model: CMX500 / VIN/Serial: MLHPC5613N5500132 Assigned Service Tech: Joe Shelton
Item Number Description Qty Req Qty Del MSRP Item Price Ext. Price 50642-K87-A30 STEP L $10.40 $10.40 $10.40
50700-K87-A00 HOLDER, L. STEP 1 $35.15 $35.15 $35.15
Environmental: $1.50 = $1.50
Job Total $47.05
Service Required
REPLACE PEG HOLDER
Service Performed
REPLACED PEG HOLDER
Job Title : DAMAGE REPAIR PARTS LIST - Model: CMX500 / VIN/Serial ::MHPC5613N5500132 Triage Level: Triage Complete / Triage Tech:Joe Shelton - Assigned Service Tech: Joe Shelton Item Number Description Qty Req Qty Del MSRP Item Price Ext. Price 17520-MKG- TANK, FUEL (TYPE1) $395.33 $395.33 $395.33
LAOZB
50530-K87-A00 BAR, SIDE STAND 1 $18.00 $18.00 $18.00
50541-MB0-000 SPRING, SIDE STAND 1 $9.99 $9.99 $9.99
50542-MB0-611 SUB-SPRING 2 2 $7.99 $7.22 $14.44
53165-K87-A00 GRIP, L. HANDLE 1 $4.29 $4.29 $4.29
53172-K87-A00 BRKT, HANDLE LEVER $28.98 $28.98 $28.98
53178-K87-A30 LEVER. L. HANDLE $21.62 $21.62 $21.62
61101-K87-A00 FENDER, FR. $35.02 $35.02 $35.02
61102-K87-A00 BRACE, FR. FENDER $28.84 $28.84 $28.84
90108-KZL-860 bolt $3.07 $3.07 $3.07
90161-MCT-770 BOLT, FLANGE (8X40) - $2.20
90163-GHB-730
90203-KVB-900 -
94050-08070 NUT, FLANGE (8MM)
94103-08700 WASHER, PLAIN (8MM)
Shop Materials: $10.00 + Environmental: $1.50 + Labor: $556.50 (3.5 x x ) = $568.00 Job Total $1,137.12
Service Required
REPLACE DAMAGED PARTS.
Paae 2/4 Invoice Transaction Total: $1.563.75
LYR
Printed On: 03/18/2023 3:31:10 PM ( Serv. Writer: PGN - Contact ID: 35476) Status: Processed Invoice # : 245777
Honda Yamaha Husqvarna of
Type: Service Processed: 03/18/2023
Redlands
Completed: 03/18/2023
215 E Redlands Blvd
REDLANDS, CA 92373 Contact ID: 39947
Main: 909-793-2833
Fax: 909-793-2474
JONATHAN GARCIA
SAN BERNARDINO, California 92410
UNITED STATES
Mobile
CLEANING/ FUEL RELATED REPAIRS WARRANTED FOR 30 DAYS ONLY. SHOP LABOR RATE IS $159.00 PER HOUR FOR MOTORCYCLES, ATVS, AND SCOOTERS. $189.00 PER HOUR FOR WATERCRAFT. THANK YOU. ESTIMATE PRICING WILL BE HONORED FOR 30 DAYS ONLY BAR #AB005049/ EPA ID #CAL000202987
UNIT PICKED UP
SIGNATURE
Other Charges Totals
Shop Materials + $16.36 Sub Total + $1,508.53
Environmental + $3.00 Tax $55.22
Labor + $874.50 *** Invoice Total $1,563.75
Item Total + $614.67 Amount Paid - $1,563.75
*** Transaction Total = $1,563.75
Total Other Charges= $1,508.53 Balance Due = $0.00
Deposit Paid $0.00
Payment Details Tax Name Tax Amount
California $45.75
Customer Credit $959.51
Redlands ( City ) $9.47
Goodwill Service $51.04
Visa - ( 1775) $553.20
Signature
Paae 4/4 Invoice Transaction Total: $1.563.75
8XW5 6X
enterprise
Owner: ENTERPRISE RENT-A-CAR COMPANY OF LOS ANGELES, LLC RENTAL AGREEMENT SUMMARY NO. 8XW56X ACCOUNT: XEMP RENTAL FIXED LOYALTY FT#
RATE PLAN GDS
RENTAL LOCATION RENTAL DATE RETURN LOCATION
RETURN DATE
| RIALTO BLOOMINGTON 02/17/2023 RIALTO BLOOMINGTON 03/03/2023 1585 W VALLEY BLVD 585W VALLEY BLVD
BLOOMINGTON, CA 923162222 RENTAL TIME RETURN TIME
BLOOMINGTON, CA 923162222
909) 879-7930 5:22 PM (909) 879-7930 12:00 PM
GARCIA, JONATHAN
XXX XXXXX XX DRIVER'S LICENSE NUMBER XXXX ISSUE DATE
SAN BERNARDINO, CA 92410
(xxX)XXX-XXXX EXP. DATE XX/XX/XXXX ISSUING STATE CA DOB XX/XX/XXXX
LOCAL ADDENDA
LES WARNING: OPERATING, SERVICING AND MAINTAINING A PASSENGER VEHICLE OR OFF-ROAD VEHICLE CAN (EXPOSE YOU TO CHEMICALS INCLUDING ENGINE EXHAUST, CARBON MONOXIDE, PHTHALATES, AND LEAD, WHICH
ARE KNOWN TO THE STATE OF CALIFORNIA TO CAUSE CANCER AND BIRTH DEFECTS OR OTHER REPRODUCTIVE HARM. TO MINIMIZE EXPOSURE, AVOID BREATHING EXHAUST, DO NOT IDLE THE ENGINE EXCEPT AS NECESSARY,
SERVICE YOUR VEHICLE IN A WELL-VENTILATED AREA AND WEAR GLOVES OR WASH YOUR HANDS FREQUENTLY WHEN SERVICING YOUR VEHICLE. FOR MORE INFORMATION GO TO WWW.P65WARNINGS.CA.GOV/PASSENGER-VEHICLE.
DAMAGE WAIVER NOTICE: RENTER ACKNOWLEDGES RECEIPT OF ORAL DISCLOSURE THAT DAMAGE WAIVER, I (WHICH MAY ALSO BE KNOWN AS LOSS DAMAGE WAIVER OR COLLISION DAMAGE WAIVER); MAY BE DUPLICATIVE OF COVERAGE MAINTAINED UNDER HIS OR HER OWN POLICY OF MOTOR VEHICLE INSURANCE. THE PURCHASE OF DAMAGE WAIVER IS OPTIONAL AND MAY BE DECLINED.
*ESTIMATED TOTAL EXCLUDES CHARGES THAT CANNOT BE DETERMINED AT THE TIME RENTAL COMMENCES
RENTER ACKNOWLEDGEMENT OF LOCAL ADDENDA
RA # 8XW56X
RENTER COPY
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8XW56X
RA # 8W56X
enterprise
PAGE 2 OF 3
ORIGINAL VEHICLE REPLACEMENT VEHICLE
MODEL TIGU MODEL
COLOR GRAY DK COLOR RENTER DECLINES OPTIONAL DAMAGE WAIVER (CDW or DW) AND RENTER ACCEPTS OPTIONAL DAMAGE WAIVER (CDW or DW) AT
ASSUMES DAMAGE RESPONSIBILITY. SEE RENTAL AGREEMENT FEE SHOWN IN CHARGES SECTION OF THE RENTAL AGREEMENT LICENSE NO. IN LICENSE NO. IN
JACKET. SUMMARY. SEE RENTAL AGREEMENT JACKET.
8UKC985 DECLINES DW
ACCEPTS DW
MILEAGE
UNIT NO. OUT UNIT NO. OUT RENTER X. RENTER X
7VVKC2 49009 RENTER DECLINES OPTIONAL PERSONAL EFFECTS COVERAGE RENTER ACCEPTS OPTIONAL PERSONAL EFFECTS COVERAGE (PEC). SEE RENTAL AGREEMENT JACKET. (PEC) AT FEE SHOWN IN CHARGES SECTION OF THE RENTAL CONDFION AND FUEL X I OF KEYS: CONCITION AND FUEL X AGREEMENT SUMMARY. SEE RENTAL AGREEMENT JACKET.
LEVEL AGREED TO 1 OF KEYS:
LEVEL AGREED TO RENTER
DECLINES PEC ACCEPTS PEC
RENTER X RENTER X
RENTER DECLINES OPTIONAL SUPPLEMENTAL LIABILITY RENTER ACCEPTS OPTIONAL SUPPLEMENTAL LIABILITY PROTECTION (SLP). SEE RENTAL AGREEMENT JACKET. PROTECTION (SLP) AT FEE SHOWN IN CHARGES SECTION OF THE
MENIALAGHEEMENT SUMMARY SEE RENTALACRE MENE MAKAT
MINCSHIELD CONDITION: WINDSHELD CONDITION:
DECLINES SLP ACCEPTS SLP
RENTER X RENTER X
HENICHUECUNES •PIONAL ROADSIDE ASSISTANCE RENTER ACCEPTS OPTIONAL ROADSIDE ASSISTANCE PROTECTION PROTECTION (RAP). SEE RENTAL AGREEMENT JACKET. KAP AL FEE SHOWNIN CHARGES SECONOF THE RENTAL X* DIENT - SCRATCH X- DENT - SCRATCH O-MISSING
CONCITION SAME ON RETURN YeS NO AGREEMENT SUMMARY. SEE RENTAL AGREEMENT JACKET.
CONDITION SAME ON RETURN Yes No
OUT E 1/8 1/4 3/8 1/2 5/8 3/47/8 OUT E: 1/8 1/4 3681125/83/47/8 DECLINES RAP ACCEPTS RAP
RENTER X RENTER X
IN 1/8 174 3/8 1/2 5/8 3/4 7/8 E 1/8 1/4 3/8 1/2 5/8 3/4 7/8 F BATTERY OUT%: BATTERY IN %: BATTERY OUT %: BATTERY IN %:
BILLING CYCLE: DAY = 24 HOUR PERIOD
STATUS CHARGES PRICE/UNIT DURATION CURRENT CHARGE
TIME & DISTANCE $128.75/WEEK 02/17 - 03/03 $257.50
TIME & DISTANCE $27.50/DAY 03/03 - 03/03 $27.50
NO CHARGE MILEAGE $0.00/RENTAL
DW $9.00/DAY 02/17 - 03/03 $135.00
OPTIONAL SUPPLEMENTAL LIABILITY
$8.75/DAY
PROTECTION 2
OPTIONAL RAP $5.99/DAY
VEHICLE LICENSE RECOVERY FEE $0.95/DAY 02/17 - 03/03 $14.25 SALES TAX 7.75%/RENTAL 02/17 - 03/03 $22.09
PREPAID FUEL CHARGE $4.73/GALLON
FUEL CHARGE $6.88/GALLON
ESTIMATED BALANCE DUE $456.34
HARGES SHOWN MAY BE SUBJECT TO CHANGE IF THE VEHICLE IS NOT RETURNED EITHER AT THE AGREED DATE AND TIME OR LOCATION, IF A REFUELINC CHARGE IS INCURRED, OPTIONAL PRODUCTS ARE ADDED/REMOVED, THE CAR CLASS IS CHANGED AND/OR ANY OTHER ITEMS OF THE CONTRACT ARE MODIFIED A:
AGREED BETWEEN THE RENTER AND RENTAL AGENT.
Mastercard xxxxxxxxxxxx1775 AUTH $717.38
COMPANY REFERENCE NUMBER
BILL-TO - N
84CBR 32B A
ADDITIONAL AUTHORIZED DRIVERS):
I REQUEST OWNER'S PERMISSION TO ALLOW THE FOLLOWING DRIVERS) WHO IS UNDER MY CONTROL AND DIRECTION TO DRIVE THE RENTED VEHICLE FOR ME AND ON MY BEHALF. I AM RESPONSIBLE FOR THEIR ACTS WHILE THEY ARE DRIVING AND FOR FULFILLING THE ADDITIONAL TERMS AND CONDITIONS OF THE CONTRACT.
NO OTHER DRIVERS PERMITTED
RA # 8XW56X
RENTER COPY
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