CITY OF RIALTO CITY CLERK'S DATE STAMP
CITY OF LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 MAR 10 PM 2:19
TO PERSON OR PROPERTY
RECEIVED
CITY CLERE
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).
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: 150S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Lelia Deborah Robertson
FULL NAME DATE OF BIRTH
Rialto, CA 92376
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 Bracy Hawkins Law, P.C.
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 468 W. 5th St., Suite 104, San Bernardino CA 92401
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: Various dates _ TIME: Unknown • AM O PM
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.
On the premises of the Rialto Fire Department, Rialto Police Department.
3. HOW DID DAMAGE OR INJURY OCCUR?
Please see attachment.
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.
Impermissably accessing and running Mrs. Robertson's personal information through the State of California's "CLETS" system and other systems without a legitimate law enforcment purpose, by unauthorized personnel and for improper, unauthorized and unnecessary reasons.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,000,000.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: economic and non-economic loss, penalties, etc. Amount: $_ 1.000,000.00 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1,000,000.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $1,000,000.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Confidential NAME: Rialto Police Department
ADDRESS: ADDRESS: 128 Willow Ave., Rialto, CA 92377
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: L AM 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.
CERTIEY (OR DECLARELINDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Lelia D. Robertson March 9, 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