CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 JUN 14 AM IO: 57
RECEIVED
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 CLERA
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: 150S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Daniel Berumen
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 06/09/2023 _ TIME: 1:10 • AM IPM
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.
North willow Avenue in Rialto No Grove Street
1055 St by GroveSt and willow Ave
3. HOW DID DAMAGE OR INJURY OCCUR?
console carthing My vehicle and damaged o center to completely be torn ott. Top left as if pulled to hard. Rialto Police officers
4. WERE POLICE AT THE SCENE? EYES 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.
City of Rialto officer that pulled me over was
C. Rodriguez officer ID 00 02511 he Searched my vehicle aggresively Causing Damage
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $. 920.44 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Center Console Arm Rest 06/04/23 Amount: $ 603.92 Item/Date: Driver Sunvisor 06/04/23 Amount: $ 316.52
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $- ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $
Item/Date:
Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $.
NAME: Amanda Calles 7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
TELEPHONE: ( )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: L
DATE: TIME:
DATE: TIME: ДАМ • РМ
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. 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 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 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.
North Willow Ave. CURB X
4. 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.
Doniel Berumen
SIGNATURE OF CLAIMANT OR AGENT
Daniel Berumen 06/14/23
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 - 150S. PALM AVE., RIALTO, CA 92376 1 of 3
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SUGGESTED SERVICES
Job
BODY EQUIPMENT Quote
IMMEDIATE ATTENTION
DRIVER SUNVISOR COMING APART
316.52
Qty Part Number Part Description Price
Ext Price
1.00 51-16-8-065-553 SUN VISOR WITH LABE
187.60 187.60
Misc Code Misc Description
Ext Price
PVA DONATION - PARALYZED VETE
0.00 Labor 0.50 Hrs 112.50
Parts 187.60
Misc
Tax (16.42
Total 316.52
Job
Quote
INTERIOR TRIM IMMEDIATE ATTENTION
CENTER CONSOLE ARM RESET ASSEMBLY COMING APART 603.92
Qty Part Number Part Description Price Ext Price
1.00 51-16-9-317-577 CENTER ARM REST F T
555.33 555.33
Misc Code Misc Description
Ext Price
PVA DONATION - PARALYZED VETE
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Labor Hrs 0.00
Parts 555.33
Misc * 52
Tax 48.59
Total 603.92
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