CITY CLERK'S DATE STAMP
CITY OF RIALTO 023
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY CITY CLERK RECEIVED MAR 22 PM L: 05
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 §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:
Jordan Ramirez
FULL NAME DATE OF BIRTH
CA 92411
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: 03/19/2023 TIME: 11 pm GAMERM
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.
Intersection of W Second St and N Larch Ave
3. HOW DID DAMAGE OR INJURY OCCUR?
I was driving East bound on W second st and right
before entering the intersection I hit a pothole, caving my tive to pop, Whee to crack + damage to the steering
4. WERE POLICE AT THE SCENE? •YES NO WERE PARAMEDICS AT THE SCENE? DYES ENO Control arm.
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 pothole on w second st just before the intersection entering N Larch Ave caused the damage.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 3,711. 54 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Pepe's Towing / 03/20/2023 Amount: $ /75.00
Item/Date: Fairview Ford Sales Inc. Service Advisor Amount: $ 3,536. 54 Department 03/20/2023
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 3,711.54 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: PePe's Towing /03/26/2023 Amount: $_/75.00
Item/Date: Fairview ford Sales, Service Advisor Department Amount: $ 3, 536.54 TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 03/20/2023 $3,711.54
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Cristofer Gonzalez NAME: Leslie Plascencia
ADDRESS: ADDRESS:
Kialto, CA 192376 CA 92334
TELEPHONE: TELEPHONE
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: _ ADDRESS: _
TELEPHONE: ( TELEPHONE: |)
DATE: _ TIME: •AM PM DATE: - TIME: • AM 0 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.
N GLENWOOD AVE East
Pothole
CURB N LARCH AVE South
North
SIDEWALK
SECOND
west
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.
CERTER UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
lordan Kamirez March 22, 2023
TYPE OR PRINT NAME
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 : P
CITY CLERK
KECEIVED
2023 MAR 22 PM 4: 05 03/22/23
CITY OF RIALTO
CITY OF RIALTO
2023 MAR 22 PM 4: 05
RECEIVED
CITY CLERK
03/22/23
N LARCH AVE
Pepe's Towing Service Receipt
PERES PO Box 7450, Moreno Valley CA 92552 #23-0320-9409 Phone: (951) 682-5682 | Fax: (951) 682-5030
Tosing Seroice CITY OF RIALTO Printed 3/21/2023
2023 MAR 22
REGEYERK PH 4: 05
CLERK
Field Tows
Invoice # 23-0320-9409 Authorized by Field Tows
Call # 9409 Tow From 207 N Glenwood Ave
Dispatcher Gina Acosta Tow To San Bernardino, CA 92411, USA Driver David L.
Truck TRK 40
Date/Time Requested 3/20/2023 @ 1:25 AM
Date/Time Dispatched 3/20/2023 @ 1:25 AM
Date/Time Enroute: 3/20/2023 @ 1:26 AM
Date/Time Arrival: 3/20/2023 @ 1:35 AM
Date/Time Departure 3/20/2023 @ 1:59 AM
Date/Time Completed 3/20/2023 @ 2:13 AM
Contact , (909) 676-3183
Year Make Model Color VIN Plate Odometer
21 Ford Ranger Gray 39730K3 -
Charge Description Quantity Price Line Total
TOWING SERVICE 1 $175.00 $175.00
Grand Total $175.00
Amount Due: S0.00
/isa payment (Ref # 108127) of $175.00
applied on 3/20/2023
Pepe's Towing Service appreciates your business; if you have any questions regarding this invoice, please contact us at 951-682-5682. Thank you. Damage Disclaimer: I Have been advised that my vehicle may be damaged if winched, towed, unlocked, jump started, tire changed or left on unattended premises. I recognize the difficulty involved and I agree not to hold Pepe's Towing Service responsible for such damages should it result. I, the undersigned do hereby certify that I am legally authorized and entitled to take possession of the vehicle described and all personal property therein. I have received the vehicle and all personal property in satisfactory condition.
Signature:
Driver Signature:
CA# 117433 USDOT: 1005094
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice X 06798 ramirez.xls +
Estimate Customer
FARVIEW Ford
Repair MISC TOTAL
wheel assembly 1,213.04 106.141 1,319.181
righ steering knuckle 487.5 414 36.225 937.725
right sway bar link 43.42 3.799 47.219
brake backing plate 30.73 2.689 33.419
tire (bridgestone dueler 9003 007160) 1,024.05 1,024.05 alignment 174.95 174.95
0 0
0 0
0 0
0 TOTAL 1,686.5 1,701.19 148.854 0 3,536.544
ADVISOR Alexander Mariscal
DIRECT LINE 909 386 0276
EMAIL [email protected]
CITY CLERK RECEIVED 2023 MAR 22
CITY OF RIALTO
PM 4: 05