CITY OF RIALTO : CITY ORNAL TOP
СТАНО.
CALTFORNI LIABILITY
2023 JUN 20 PM 12:27
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
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).
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:
Liliana Cerpa
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 Napolin Law, APC
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(it different from home address provided above): 430 N. Vineyard Ave., Suite 125, Ontario, CA 91767
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 03/17/2023 TIME: 2:30 • АМ БІРМ
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.
Liliana Cerpa, was stopped on the eastbound freeway off ramp of the 10fwy, at the intersection of Cedar and number 1 lane in the City of Rialto. The signal at the intersection of Cedar tured green and vehicles proceeded forward Liliana accelerated forward, traveled for a short distance and then was hit from behind by a Rialto vehicle
3. HOW DID DAMAGE OR INJURY OCCUR?
Liliana immediately felt dizzy and a headache. She immediately felt back pain, shoulder pain and neck pain.
4. WERE POLICE AT THE SCENE? IN 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.
Alyssa Michelle Burk was not paying attention because she was looking down at her phone.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ To be determined HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimales, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
90° 90° 180°
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ To be determined 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:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
0 IT
NAME: Cadman Chiropractic NAME: _ -. C
ADDRESS: 9019 Sierra Ave St. CITY OF RIALTO
ADDRESS: _
Fontana CA 92335
TELEPHONE: (909) 822-2225 TELEPHONE: 1).
DATE: 03/30/23 TIME: • AM 0PM DATE: BAM
TIME:
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 comers.
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 vehicte 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
Liliana Cerpa 05/11/2023
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 :
:
Liability Claim Form (PDF)
Final Audit Report 2023-05-12
Created: 2023-05-11
By: Alexander Napolin ([email protected])
Status: Signed
Transaction ID: CBJCHBCAABAApq7oirh-K3AoN1 IMh3vHbSJG2Cvyg_3n "Liability Claim Form (PDF)" History
- Document created by Alexander Napolin ([email protected]) 2023-05-11 - 8:57:20 PM GMT. IP address: 209.40.79.197
Es Document emailed to [email protected] for signature :
2023-05-11 - 8:57:44 PM GMT
• Email viewed by [email protected]
2023-05-12 - 1:30:13 AM GMT- IP address: 104.28.85.113
CITY CLERK RECEIVEL 2023 JUN 20 PM 12:27 CITY OF RIALTO Os Signer [email protected] entered name at signing as Liliana Cerpa 2023-05-12 - 1:32:51 AM GMT- IP address: 76.86.116.214
Do Document e-signed by Liliana Cerpa ([email protected]) Signature Date: 2023-05-12 - 1:32:53 AM GMT - Time Source: server- IP address: 76.86.116.214 Agreement completed.
2023-05-12 - 1:32:53 AM GMT
Adobe Acrobat Sign
CITY OF RIALTO
PROOF OF SERVICE
1 STATE OF CALIFORNIA 2023 JUN 20 PM 12:27
2 RECEIVEL
COUNTY OF SAN BERNARDINO CITY CLERA
4 I am employed in the County of San Bernardino, State of California; I am over the age of eighteen years and not a party to the within entitled action; my business address: 430 N.
Vineyard Ave., Ste. 125, Ontario, CA 91764.
On June 14, 2023, I served the within entitled document: on the interested party by the method 7 of service indicated below, and addressed as follows:
8 NAME & ADDRESS
9 Rialto City Clerk's Office
10 150 S. Palm Avenue
Rialto, CA 92376
11 12 XBY MAIL: I am "readily familiar" with the firm's practice of collection and processing 13 correspondence for mailing. Under that practice, it would be deposited with US Postal Service on the same day with postage thereon fully prepaid at Ontario, California, in the ordinary course 14 of business. I am aware that on motion of the party served, service is presumed invalid if postal cancellation date or postage meter date is more than one day after date of deposit for mailing in 15 affidavit.
16 OBY FACSIMILE: I submitted the above-referenced documents to the above-referenced recipient by directing such facsimile transmittal to the following number: Unassigned. 17 18 OBY PERSONAL SERVICE: I delivered such envelope by hand to the office of the addressee. 19 OBY ELECTRONIC MAIL: I submitted the above-referenced documents to the above- referenced recipient by directing such electronic mail transmittal to the following electronic mail 20 address: Unassigned.
21 I declare under penalty of perjury under the laws of the State of California that the above is true 22 and correct.
23 Date: 6/14/2023
24 Brenda Mendoza 7
25 26
27 28
- 1-
PLAINTIFF'S REQUEST FOR ADMISSIONS - SET ONE
CERTIFIED MAIL®
Napolin Law Firm TA ANA CA 926
430 N. Vineyard Avenue, Suite 125 UN 2023 PM 5 E US POSTAGE Ontario, CA 91764 $ 008.10°
02 1P
0001203400 JUN 14 2023
MAILED FROM ZIP CODE 91764
7022 1670 0003 0056 3398
Rialto City Clerk's Office 2023 JUN 20 PM 12:27 CITY OF RIALTO 150 S. Palm Avenue nraciuca
Rialto, CA 92376
92376-648799