CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2023 MAY - 2 PM 4: 32
TO PERSON OR PROPERTY
RECEITEL
1. Claims for dealin, injury to person, or to personal propery must be filed not later than six 6) months after the ocumence (Gov. Code g91. FLEX
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:
LUIS ENRIQUE ESTRADA MARQUET -
FULL NAME DATE OF BIRTH
RIALTO CA -
HOME ADDRESS INCLUDING CITY, STATE & ZIP 92376 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: 12-16-2099 TIME: 09:17 DAMS 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.
I MERRIL AVE SLIAC AVE
SCHOOL PARKING 10T
478 MERRiL AVE RIALTO CA CROSS STREET LILAC ST
3. HOW DID DAMAGE OR INJURY OCCUR?
OFFICER SAID I HARD HAD TO SURRENDER THE TRAILER
ATTACHED TO MY TRUCK INDICATING THE REGISTRATION 1S
PEEMANENT AND DOES NOT EXPIRE AS IT DOES NOT HAVE MOTOR
4. WERE POLICE AT THE SCENE? YES •NO WERE PARAMEDICS AT THE SCENE? • YES ENO
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.
RIALTO OFFICER, VILLAREAL #1335 WrONGFULLY DETAINED
MY TRAILER AND CAUSED ME TO INCUR UNNECESSARY
FEES
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $841.80 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: REPES TOWING SERVICE 12-19-92 Amount: $. 625 Item/Date: 15O S. PALM AVE RIALTO CA 9237 6Amount: $. д16.80 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $841.80 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: NAME:
ADDRESS: ADDRESS: —
TELEPHONE: _) TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: | )
DATE: TIME: LAM LPM DATE: TIME: • AM I 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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
LUIS ENRIQUE ESTRADA MARQUEZ 05-02-2023
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