CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2023 JUN 13 PM 5: 15
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:
Fredy Gonzalez
-
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: 04-01-23 TIME: 2:00 ПАМ (ХОРМ
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.
Oficcer K- ball Lost any ID Card
3. HOW DID DAMAGE OR INJURY OCCUR?
Car acadant on linden / Foothill ave
4. WERE POLICE AT THE SCENE? AYES DINO WERE PARAMEDICS AT THE SCENE? *YES ONO
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.
Officer K-bull took my license ID and Lost 1t
after I was tacking to the ER on 4-1-23 day
of my car acadent-
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:
Item/Date:ID license card -1-23 Amount: $ 33
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 37 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hem/Date: license ID Card 4-1-27 Amount: $ 3]
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: (
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: (
DATE: TIME: • 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.
Foothill ene
-CURB - -
AVE
PARKWAY
/
Homedepo tenDEWALK
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
Fredy Gonzalez 6-6-23
TYPE OR PRINT NAME DATE
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