CITY OF RIALTO CITY CLERKS DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 SEP 15 AM|: 04
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). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING
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:
KEVIN MCCONKO
FULL NAME DATE OF BIRTH
Rialto
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 92377
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TFI FPHONF NO
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Rialto Ca, 92377
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 01|11/2023 _ TIME: 11145 DAM EPM
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. (ECAR And bAseline
3. HOW DID DAMAGE OR INJURY OCCUR?
I'WAS WRODtilly detAIn DyAUlICe And ASSAUHEd
When place in handcuff
4. WERE POLICE AT THE SCENE? / YES • NO WERE PARAMEDICS AT THE SCENE? •YES I 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.
Ralto police handeuff me and the handlutt was exteze
hours is the back of the police cAR
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 75,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
01-16-2023 Amount s/ 00, 00D
Item/Date:
Item/Date: Hill tReAting with DR. Amount: $.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $200,000 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 01-18-2023
Amount: $
Item/Date: ON going
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $700,000
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: UnknOWn
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: | ) TELEPHONE: (
-
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DAȚE/TIME DOCTORS) OR HOSPITALS) VISITED: NAME: METRODOLITAR FAM, lUMedICAl CIINIC NAME: — OptoM
ADDRESS: 425 E FOOtRIll BND. RIGHtO
ADDRESS:
Ca. 92378
TELEPHONE: 909, 540
TELEPHONE: ( )
DATE: 61~14-2223 TIME: 9,00
AM 0PM DATE: TIME: • AM OPM
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 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.
CURB
PARKWAY
7 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 VHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I BERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
120IV MCCONIO 09-2-0023
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 (RadNet sen Bernardino Redlands Groves, Le motinda OpeRtmasing Request form SCHEDULING:
Appointment Date:
_Appointment Time: __ Today's Date: 1120/2023
Patients Name: K-P.vin Mcconico
Date of Bath
Clinical History Reason for ExamS holder Pair
Insurance infomatin avermore Healthflan Patents s909789-3696 Alternate Phone:_
Referring Physician. esus Pacis
- Physician Signature: Phone:
(CT Contrast Studies Only] Labs needed if: _ Diabetes
.. Rena Disease
If Labs have been completed within the past 30 days please provide values and fax lab results: Creatinine / GFR • Call In STAT results • STAT/Wet Read
• Previous Films (Y) (N) location:
© Additipnal Report to: • Send CO with Patient • Other:
MR CT
ultrasound PET/CT
MRI Diagnostic CT
• Contrast as Indicated Abdomen, • PET/CT, Skull Base to Mid-thigh • contrast as Indicated C Abdomen Limited • PET/CT, Whole Body (Melanoma) • 3D Rendering as indicated 3D Rendering as indicated
Liver_Galibladder
• With & Without Contrast • With & Without Contrast _Right Upper Quadrant • PET/CT, Brain • With Contrast • With Contrast • NAF bone
• Without Contrast • Abdomen w/Doppler if Indicated
• Without Contrast • Renal:
• Contrast, as Indicated
• 3D Recon • 3D Recon •w/bladder Nuclear Medicine
D Brain • Brain D Bladder:
• orbits • Aorta/Retroperttoneal • Bone Scan
•w/sceclal attention to lAC —Whole Body_Limited _3-phase • IAC Middle Ear a Perk: Ultrasound (Transabdominal
•w/special attention to Pitultary and tansvaginal) • Bone SPECT • NeuroQuant • Maxillofacial - Facial Bones • Permic Ultrasound Complete • Thyrold Uptake and Scan A Orbits _Bones Implants
0 TM • sinus (Maxilofacia) (Tra nisabdominal only) • Parathyroid • Neck - Soft Tissue - Neck (soft tissue) • Pelvic Ultrasound (Transvaginal only) Duver/Spleen • Spine: • Spine: • Scrotum_w/Doppler • Gallbladder (HIDA) with EF • Thyroid • Gallbladder (HIDA) without Ef
_Certical_Thorac/c_ Lumbar _CervicalThorack_Lumbar •Blopsy/Aspiration/Anjection • Extremity: Joint_ Left _Right • Extremity: _eft _Right • GI Emptying Specify body part Area • Renal _Captopril _Lasix
Specify body part • Hysterosonogram
• Extremity: Non-joint _Left_Right • chest • Other -
Specify booy part D other:
• Abdomen
• Breast_CAD • Abdomen and Pelvis Vascular Studies X-Ray _MassImplant • Urogram (abdomen/peivis) • Artertal Doppler (Duplex) • MR Guided Breast Biopsy • Head:
• Peivis • Carotid Doppler (Duplex) _Skull Orbits Sinuses • Chest
• Treatment Plan: Venous Doppler (Duplex). DO Spine:
• Abdomen • Dental Planning •'venous Mapping
-Adrenals __MRCP • Enterography Venous Insuffidency Naricose Veins _Cervical _Thoracic __Lumbar • Pelvis Bony Pelvis_Soft Tissue • Myeigram • Extremity • chest: _PAPA/LAT • CSF Flow Study • Ribs:
• other: -upper _Lower __R_BI
• Enterography • Other. -Unilateral_Bilateral W/PA Ches A Prostate OB Ultrasound • Abdomen: _KUB _Two Views
• Other: CTA (Anglography) • Pelvis
• Head •OB Utrasound (TV if Indicated) • Hips w/AP pelvis, bilateral MR Angiography
• With & Without Contrast • Neck • Umited (Viability, Heart Beat Unlateral Left _Right • Without Contrast • Extremity: _Upper __Lower Postion, Fluid, Placental Location) [Extremity:. • Chest Left Right Bilateral
C Contrast, as indicated • Aorta and runoff vessels • Folich up (specty documented Specily Body PastouTer • Brain problern)
• Neck • Carotids • Abdomen • other._
• Pelts
• chest Fluoroscopy
• Abdomen CoronaryCalcium Score EP Plan
• Arthrography DEXA
-AortaRenal
• Aorta and runoff vessels Creadnine: Spedfy body part. • Bone Density
• Pelvis Bun: Reason for bone density:
• Extremity: _Left Right ,Esophagram
• other:_ Lab Date: • Hysterosalpingogram (HSG) Date of last exam:
MR Arthrography_Lef _Right LUG/w/SBFT
• Shoulder Small Bowel Breast Imaging
• Elbow
METROPOLITAN FAMILY MEDICAL CLINIC , Barium Enema *Mammography referral sheet • Wrist other_
available
• Hip 425 C FOOTATA BLVD., RIALTO CA 92376
• Ankle Pl 909-546-1698/NAM 969-546-1061
D other:
please brines this ferm and your insurance card with you on the day of your exart.
RadNetimaging.corr
Name: Mcconico, Kevin DOB: 07/10/1977
Date: