CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2023 JUN -9 PM 12: 08
TO PERSON OR PROPERTY
RECEIVEL
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). CITY CLERK
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:
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Andrea ellis
FLILL NAME
DATEOF BIRTH
Rato, CA 923761
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: 4/2/23 TIME: 08: 27 DAMOPM
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 actt turn rom cuça votus st
Fung of me made tan far aton
4. WERE POLICE AT THE SCENE? YESTONO 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.
untilled potholes that were unavordable
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 150- HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DANA TO Sed TiRe Replacement 100
Amount: $
50 HenDar Racked rim Repair Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $150- 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) than McFanden NAME:
NAME:
ADDRESS:
ADDRESS:
Kalto, La 92310
TELEPHONE: L Minor chila) TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME: _
ADDRESS:
ADDRESS: _
TELEPHONE: L TELEPHONE: | )
DATE: TIME: DAM • 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. f 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 hen 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.
High, choo
Merrill CURB
PARKWAY
SIDEWALK
North
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 MYINFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
And earls 424/23
YPE 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 NO #
BLOOMINGTON
DATE
TIRES #1
Shop: (909) 990.5002
NEW 8 USED METHOD OF PAYMENT L CASH L CHECK
18829 Valley Blvd. • Bloomington, CA 92316
NAME PHONE HOME BUSINESS CHARGE
YEAR, MAKE & MODEL
• DEBIT CARD CREDIT CAR
ADDRESS
STATE ZIP
VIN NUMBER ODOMETER READING LICENSE NO.
ENGINE SIZE
DESCRIPTION AMOUNT
NEW TIRE • USED TIRE
VALVES PATCHES PLUGS RIMS REPAIR
ROTATION COMPUTER BALANCE ALIGNMENTS
LF RF
L BRAKES SHOCKS SUSPENSION
SPARE
Tire Disposal Fee
USED TIRES NO GUARANTEE
BLOOMINGTON TIRES #1 do not guarantee used tires or used wheels. All work is final. No refunds or exchanges. Customer is satisfied based Sub Total on signing this invoice. Note: All used tires are only for temporary used and must be replaced as soon as possible with a new tire.
BLOOMINGTON TIRES is not responsible for lost articles, i.e. Center caps, hub caps attached to wheels, spacers and/or loose lug nuts, etc.; as well as not responsible for damage or inconvenience any used tire may cause you and/or your vehicle. Deposit If the customer wants to keep the tires or wheels that were removed from their vehicle, they must request it before leaving the location. If the client requests that we retain their w ad of 7 days (No exceptions).
All Deposits Are final. TAX
Print Sign TOTAL
NO #
BLOOMINGTON
DATE
TIRES #1
Shop: (909) 990.5002
METHOD OF PAYMENT • CASH
NEW & USED 18829 Valley Blvd. • Bloomington, CA 92316
NAME PHONE HOME BUSINESS YEAR, MAKE & MODEL • CHARGE
DEBIT CARD I CREDIT CARE
ADDRESS CITY STATE ZIP
VIN NUMBER ODOMETER READING LICENSE NO. ENGINE SIZE
DESCRIPTION AMOUNT
NEW TIRE L USED TIRE
VALVES PATCHES PLUGS RIMS REPAIR
ROTATION COMPUTER BALANCE ALIGNMENTS
LF RF
BRAKES SHOCKS SUSPENSION
SPARE
LR RR
Tire Disposal Fee
USED TIRES NO GUARANTEE
BLOOMINGTON TIRES #1 do not guarantee used tires or used wheels. All work is final. No refunds or exchanges. Customer is satistied based Sub Total on signing this invoice. Note: All used tires are only for temporary used and must be replaced as soon as possible with a new tire.
BLOOMINGTON TIRES is not responsible for lost articles, i.e. Center caps, hub caps attached to wheels, spacers and/or loose lug nuts, etc.; as well as not responsible for damage or inconvenience any used tire may cause you and/or your vehicle. Deposit If the customer wants to keep the tires or wheels that were removed from their vehicle, they must request it before leaving the location. If the client requests that we retain their whole it will be for maciod of 7 do /No Axceptions). TAX All Deposits Are final.
TOTAL
Print Sign