CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 MAR - 9 PM 3:47
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Melinda K. Chares
DATE OF BIRTH
Riato, CA. 92371
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
L
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):
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.
Pothole on corner ot Shamwood + Riverside Ave.
3. HOW DID DAMAGE OR INJURY OCCUR?
Pothole busted "' tires and damaged I rim.
4. WERE POLICE AT THE SCENE? DYES ENO WERE PARAMEDICS AT THE SCENE? DYES DONO
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.
unreddined mahole a intersection of Meadow Ar t
Riverside ide rebad to alt both ot my large vehide.
Towed tow truck to tine shope
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Feb 24.2013 644.37
Item/Date: Amount: $
Item/Date: Tuesday Feb 28, a Amount: $ 13l67
Tow- 90.00 Tow - 90.00
2-24-23 2-25-13 Tine - 46.87
Tire- 554.37
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 781.24 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: vi tor Truck Yukan Deali
Amount: $ 480.54
Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 480.54
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Delinda NAME: Tamason
ADDRESS:
Klato. ADDRESS:
01377 92311
TELEPHONE:
TELEPHONE:
B. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: _
NAME:
ADDRESS: _
ADDRESS:
TELEPHONE:
TELEPHONE: | )
DATE: TIME: • AM 0] PM
DATE: TIME:
DAM 0PM
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.
Riverside Ave cadaw
7, SIDEWALK E
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.
RJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGN EUR CLAIMAN OR AGENT
Melinda 1. Charles Man 4,2023
TYPE OR PRINT NAME
DATE
SO h
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 AMERICA'S TIRE 2/25/2023
10:34 AM 11:43 AM
MALINDA CHARLES MALINDA CHARLES
BALTO CA 02377 RIALTO CA 92377
(H) (H)
2019 FORD 2004 CMC Plate#: 1CREOQT
TRANSIT YUKON Miles:
Miles: 55,732
XU/XLT 350 AWD DENALI Torque Specs: 140
Torque Specs: 150
CAL 40 CA# CAL 40
Invaice - Invoice #
16065 SIERRA LAKES PKWY 1468463 1468941
FONTANA, CA 92336 FONTANA. CA 92335
909.770.5001 902.770 s0m-
Salesperson 6 Sa esterson 801
CORY A A CONNOR C
Estimated Completion Time 11:03 AM Estimateo Completion Time 10:15 AM iticle Oty Descrintion. FET -Price Article Qty Description. EET Price Amount.
Amount. 44327 -1 P 265. /20 R17
7534 2 235 /65 R16 121R C8 BSW 113S SL BSW 116.00 -116.00 NAW 210.00 420.00 RHZ PRO PRODIGY
FIR TRANSFORCE CV RADIAL H/T
ears BOLT PATTERN: 6-139.7
LT PATTERN: 5-160 42517 265 /70 R17 115T SL BSW
NAM 137.00 137.00
-LATION F:52 R:74 COR CORSA HIGHWAY TERRAIN PLS
:0017 2 CERTIFICATES FOR TIRE MILEAGE WARRANTY: 40000
115.2: 70.49 NFLAT ON = 33 8 3:
NRM REFUND, REPLACEMENT
E0017 CERTIFICATES FOR
For tire certificate details. see NAV 22.49 22.49
www.americastire.com/customer-service/certificates REFUND. REPLACEMENT :0075 STATE REQUIRED For its sardScate cetans see
1.75 3 50 to are caste com/customer-service/certificates
NAM TIRE FEE
10224 2 WASTE TIRE STATE REOU RED 1.75 1.75
2.50 5.00 NEX TIRE FEE
NRM DISPOSAL FEE
3E937 ADJUSTMENT/EA- & VAL LIFETIME
10219 INSTALLATION & 22.00 $4.00 .00 .00
NAM NAN W CERTS
LIFE OF TIRE MAINTENANCE
Terms and Conditions can be found at
www.americastire.com/customer-service/invoice -terms When replacing less than four tires. America's 18968 AAA Tire recommends that the new tires will be placed --10.00 - 20.00 on the rear of the vehicle
NAM MEMBER DISCOUNT
When replacing less than four tires, America's The tire and/or wheel you have chosen is different Tire recommends that the new tires will be placed Trom the original equipment provided with your on the rear of the vehicle vehicle and may change its handling or stability characteristics.
Further information is available from your
America's Tire salesperson.
Sub Total: 522.98
Sales Tax: 31.39
Sales Total: 554.37 Sub Total: 45.24
Sales Tax: 1.63
#/ XX00000X5694 Ath# 025092 Tendered: 554.37 Sales Total: 46.87 (VIS)
Tendered Today: 554.37 *== XXXXXXX:*45 Ath= 13-735
Tendered: 46.87 (DBT)
Tendered Total: 554.37 Tendered Today: 46.87
Tendered Total: 46.87
www.americastire.com/tire -registration
www.americastire.com/tire-registration
IEPN CALLE
Automobile Club of Southern California
AAA.com
March 07, 2023
MELINDA CHARLES Member No. 004-02784458
RIALTO CA 92377-4062
Dear Melinda Charles:
As you have requested, a synopsis of the call(s) you placed for Emergency Roadside Assistance are located on the next page(s).
If a member exceeds the number of calls allotted by the membership, the member is billed by Automobile Club of Southern California an amount which covers its cost to provide service. If the member has a AAA Plus or Premier membership, Automobile Club of Southern California also bills the member for the cost to provide extended AAA Plus or AAA Premier benefits for towing, fuel, and locksmith services.
The SERVICE CHARGE field indicates whether the member was actually charged for the service by AAA for the service received. The SERVICE CHARGE AMOUNT field indicates the amount the member was billed, or would have been billed, if the member had exceeded the number of calls allotted.
Should you have any questions, or if I may be of further assistance, please do not hesitate to call me at the number below or Toll Free: 888-222-9441.
Sincerely,
Thuy Vu
714-850-5471
ERS Administrative Services
Administrative Otfices: PO: Box 2500), Santa Ana: CA 92799-5001 Headquarters: 2001 S. Figueroa. Los Angeles: CA 90007-5254 Auta Ciub Enterprisos provides service to moro than 17 milion members East Central Missouri forthert Alabama Now Mexico Hawart vew Engian Diagnnter
We're always with you.
АДА
ERN CALID
Automobile Club of Southern California
AAA.com
Call: 1 Date: 02/25/2023 Time:
8:21 AM
Location: RESIDENCE
Problem: Tow
RIALTO, CA Tow Dest: 16065 SIERRA LAKES PKWY/FONTA
Vehicle: 2019 FORD TRANSIT 350 VAN BLACK Miles: 6
Service Charge: No Service Charge Amount: $90.00
Call: 2 Date: 02/28/2023 Time: 7:17 AM
Location: RESIDENCE
Problem: Tow
RIALTO, CA Tow Dest: 16065 SIERRA LAKES PKWY/FONTA
Vehicle: GMC YUKON BLACK Miles: 6
Service Charge: No Service Charge Amount: $90.00
Administrativo Offices: PO BOx 25001, Santa Ana CA 02700-5001 Headquarters: 2601 S Fiqueroa Los Angeles. CA 90007-3254 Auto Club Enterpnisos providos service to more than 17 milton members Mar anal Tutor Mo
We're always with you.