CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 2023 JUN 12 AMIO: 43
RECEIVEE
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occumence (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:
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:
helle L. Shor
FULL NAME DATE OF BIRTH
Fontona, CA
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 92336
12249 HollySt. Riverside, CA92509 951903-1234
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): Surpa Valley, CA92509
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 01/12/2023 _ TIME: 7:50 ШАМ • 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. enterprise
3. HOW DID DAMAGE OR INJURY OCCUR?
Tole one to neare Brad hit huge
endedin myleft rim cracking.
4. WERE POLICE AT THE SCENE? • YES 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.
nterprise Dr in the City of hiatto had a hug
othole that caused damage to my left fin
inthetrontot mular
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 725,39 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: halter's Mercedes-Benz Amount: $725,39
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 725.39 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
tem/Date: Walter's Mercedes-Benz Amount: $ 725,39
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $725.31
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: N NAME: — N/A
ADDRESS: ADDRESS:
TELEPHONE: | 1 TELEPHONE: (1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A NAME: N/A
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. để
Enterprise Dr. Ce
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. - ICERTIEK(OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
hellee Shorts 06/12/23
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 CUSTOMER #: 41688UC walter's
UNIT# 41688UC 858637 Mercedes-Benz
of Riverside
KELLEE SHORTS * INVOICE*
3213 Adams St. Riverside, CA 92504
Service: (951) 552-2141 • Parts: (951) 552-2205
FONTANA, CA 92336 Service Fax: (951) 688-2359 • Parts Fax: (951) 689-1413 HOME: PAGE 1 WaltersMercedesBenzOfRiverside.com
CONT:
BUS: CELL: SERVICE ADVISOR:
COLOR YEAR 900410 AUSTIN SCHNEIDER
MAKE/MODEL
VIN LICENSE
MILEAGE IN / OUT TAG
MOUNTAIN 18 MERCEDES-BENZ CLA250
DEL. DATE PROD. DATE WDDSJ4GB6JN530410 50378/50379
WARR. EXP. PROMISED TR925
PO NO. RATE PAYMENT
INV. DATE
02JAN18 DDO3MAY17 01JAN2022
WAIT 19JAN23 269.95
R.O. OPENED READY 19JAN23
OPTIONS: SOLD-STK: 41688UC DLR: 34130
12: 50 19JAN23 14:31 19JAN23 ENG: 27092031423607 TRN: 72401120788893 AXL: 787/151
LINE OPCODE TECH TYPE HOURS
LIST NET TOTAL
A CUSTOMER STATES TO REPLACE THE LEFT FRONT WHEEL, SOP PARTS IN STOCK
WITH PARTS, USE EXISTING TIRE THAT IS ON THE CAR
40 WHEELS, ALIGNMENT, TIRES, CHASSIS
900894 CEXP 0.60
1 246-401-17-00-7X44 EXCHANGE DISK WHEEL 37.00 37.00
WHEEL WEIGHTS 528.00 628.00 628.00
PARTS : 5.00 5.00 5.00
633.00 LABOR: 37.00 OTHER:
50379 replace LF wheel 0.00 TOTAL LINE A: 670.00
0.60 team 2 tech 900894 replaced LF wheel
***************************************************
B PERFORM A NO CHARGE MULTI POINT INSPECTION AND PROVIDE DETAILED REPORT TO CUSTOMER. INCLUDES LIGHTING, UNDER VEHICLE
COMPONENTS, UNDER HOOD FLUID LEVELS, UNDER HOOD
COMPONENTS, TREAD DEPTH, BRAKE LINING CONDITION, DRIVE TRAIN
CONDITION AND LEAKS,
MPI PERFORM A NO CHARGE MULTI POINT INSPECTION
AND PROVIDE DETAILED REPORT TO CUSTOMER.
INCLUDES LIGHTING, UNDER VEHICLE COMPONENTS,
UNDER HOOD FLUID LEVELS, UNDER HOOD
COMPONENTS, TREAD DEPTH, BRAKE LINING
CONDITION, DRIVE TRAIN CONDITION AND LEAKS,
900894 CPR 0.00
PARTS: 0.00 LABOR: 0.00 0.00
0.00 OTHER: 0. 00
50379 mpi performed TOTAL LINE B: 0.00
******---*****************************************
C CHECK AND CORRECT AS NECESSARY--ALL TIRES FOR CORRECT PRESSURES
TP CHECK AND CORRECT AS NECESSARY--ALL TIRES FOR
CORRECT PRESSURES
900894 CPR 0.00
PARTS: 0.00 LABOR: 0.00 0.00
0.00 OTHER: 0.00 TOTAL LINE C:
50379 36/36psi 0.00
*************************************
D COMPLIMENTARY CAR WASH ($19.95
VALUE) CLEAN EXTERIOR,
Original Estimate Total Additional Approved By: DRESS TIRES, Cost Authorized Date & Time Authorization
Obtained By: "HAZARDOUS WASTE DISPOSAL DESCRIPTION
Person Approval TOTALS
COSTS: We have added this LABOR AMOUNT
Telephone
saltax 15o0 Attached charge to cover costs associated
Revised Estimate Person Approva with the handling, management PARTS AMOUNT Telephone and disposal of toxic wastes or
GAS, OIL, LUBE
•Email/Fox (See Attached) hazardous
substances under
Tire pressure check/inflation service was performed. California and Federal Law. SUBLET AMOUNT RF psi LF psi RR
psi LR psi WASTE DISPOSAL COSTS *
Customer declined tire pressure check/inflation service. ALL PARTS ARE NEW By signing below, Initials TOTAL CHARGES
you acknowledge that you were notified of and authorized the UNLESS OTHERWISE (or had the opportunity to inspect) any replaced parts as requested by you. Dealership to perform the services/repairs itemized in this Invoice and that you received INDICATED. LESS INSURANCE DATE Some Parts Not Returnable SALES TAX
CUSTOMER SIGNATURE
AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE
PLEASE PAY
THIS AMOUNT
To provide you with additional information regarding our privacy practices and your rights under the California Consumer Privacy Act, NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON BACK. please access our Privacy Policy and Notice at Collection at www.waltersautogroup.com.
DealerCAP 2014 COK Global, LLC 101/19) SERVICE INVOICE TYPE 2 - SIC • "LIMITED WARRANTYIAS IS* - CALIFORNIA - 9698022 CUSTOMER COBYREG.# ARD00003021 EPA# CAL000248190
walter's
CUSTOMER #: 41688UC 858637
UNIT# 41688UC Mercedes-Benz
of Riverside
KELLEE SHORTS * INVOICE*
3213 Adams St. Riverside, CA 92504
Service: (951) 552-2141 • Parts: (951) 552-2205
FONTANA, CA 92336 Service Fax: (951) 688-2359 • Parts Fax: (951) 689-1413 HOME: PAGE 2 WaltersMercedesBenzOfRiverside.com
CONT:
BUS: CELL: SERVICE ADVISOR:
COLOR YEAR 900410 AUSTIN SCHNEIDER
MAKE/MODEL
VIN LICENSE
MILEAGE IN / OUT TAG
MOUNTAIN 18 MERCEDES -BENZ CLA250
DEL. DATE WDDSJ4GB6JN530410
PROD. DATE WARR. EXP. PROMISED 50378/50379 TR925
PO NO RATE PAYMENT
INV. DATE
02JAN18 DDO3MAY17 01JAN2022 WAIT 19JAN23
R.O. OPENED 269.95 CASH 19JAN23
SOLD-STK: 41688UC DLR: 34130
12:50 19JAN23 14: 31 19JAN23 ENG: 27092031423607 TRN: TRN:72401120788893 AXL: 787/151
LINE OPCODE TECH TYPE HOURS
LIST NET, TOTAL
VACUUM INTERIOR AND CLEAN ALL WINDOWS INSIDE AND OUTSIDE WASH COMPLIMENTARY CAR WASH ($19.95 VALUE) CLEAN
EXTERIOR, DRESS TIRES, VACUUM INTERIOR AND
CLEAN ALL WINDOWS INSIDE AND OUTSIDE
900894 CPR 0.00
PARTS: 0.00 LABOR: 0.00 0.00
0.00 OTHER: 0.00 TOTAL LINE D:
************************************* 0.00
E VEHICLE TOWED INTO DEALERSHIP--PRIOR CONDITION UNKNOWN
TOW VEHICLE TOWED INTO DEALERSHIP--PRIOR
CONDITION UNKNOWN
900894 CPR 0.00
PARTS: LABOR: 0.00 0.00 0.00
OTHER: 0.00 TOTAL LINE E:
0.00 F CUSTOMER WAITING WHILE VEHICLE IS SERVICED
WAIT CUSTOMER WAITING WHILE VEHICLE IS SERVICED
900894 CPR 0.00
PARTS: 0.00 LABOR: 0.00 0.00
0.00 OTHER: 0.00 TOTAL LINE F:
0.00 *******************
Original Estimate Total Additional Approved By:
(Parts & Labor) Cost Authorized Date & Time Authorization Obtained By: "HAZARDOUS WASTE DISPOSAL DESCRIPTION
COSTS: We have added TOTALS
this LABOR AMOUNT
charge to cover costs associated 37.00
alFax (Soo Atteched)
Revised Estimate with the handling, management PARTS AMOUNT 633.00 son Approval
and disposal of toxic wastes or GAS, OIL, LUBE
hazardous substances 0.00
under
Tire pressure check/inflation service was performed. California and Federal Law. SUBLET AMOUNT 0.00 psi LF psi RR psi LR WASTE DISPOSAL COSTS •
psi 0.00
Customer declined tire pressure check/inflation service. ALL PARTS ARE NEW By Initials TOTAL CHARGES
signing below, you acknowledge that you UNLESS OTHERWISE 670.00 were notified of and authorized the
(or had the opportunity to inspect) any replaced parts as requested by you. Dealership to perform the services/repairs itemized in this Invoice and that you received INDICATED LESS INSURANCE 0.00 DATE CUSTOMER SIGNATURE Some Parts Not Returnable SALES TAX 55.39
AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE
PLEASE PAY
THIS AMOUNT 725.39
To provide you with additional information regarding our privacy practices and your rights under the California Consumer Privacy Act, NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON BACK. please access our Privacy Policy and Notice at Collection at www.waltersautogroup.com.
DealerCAR 2014 CDK Global. LLC (01/19) SERVICE INVOICE TYPE 2 - SI2C • "LIMITED WARRANTY/AS IS• • CAUFORNIA • 9698022 CUSTOMER COB-REG.# ARD00003021 EPA# CAL000248190
Walter's Mercedes-Benz of Riverside
3213 Adams Street
RECEIPT
Riverside, CA 92504
(951) 552-2141
Customer Information:
Kellee Shorts Invoice Details:
Invoice #: M2JTCW1H6C
Invoice Date: Thursday, January 19, 2023 04:15
PM
(XXX) XXX-X844 Repair Order/Ref #: 858637
Description of Product/Services
Amount
Service Performed
$ 725.39
Payment Details:
Paid On: Thursday, January 19, 2023 04:15 PM
Credit Card: XXXXXXXXXXXX4627 exp XX
/XXXX
Card Type: MAST
Payment Type: Chip
Confirmation #: 037935
Customer Signature
Dealer Associate: Austin Schneider
Cashier: Tiffany Limon
THANK YOU!
Walter's Mercedes-Benz of Riverside Processed by myKaarma eBridge Payments