CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 ОСТ 13 АМ 9:30
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:
WENdy VanDerenter
FULL NAME -
DATE OF BIRTH
Rialta Cali
HOME ADDRESS INCLUDING CITY, STATE & ZIP
92376 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): Same as abore
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: - 10/12/23 _ TIME: _ 8:00 ДАМ ОРМ
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.
Foothill and Cedar.
3. HOW DID DAMAGE OR INJURY OCCUR?
Construction and Roadwork for several months
Off and on near my residence.
4. WERE POLICE AT THE SCENE? •YESENO WERE PARAMEDICS AT THE SCENE? • YES DINO
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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $14500 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: TiRe 10-12-23 bolts and Nail Amount: s 14502 Item/Date:
Amount: $.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $145°0 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: ire Repair
Amount: $_/ 453
Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach aditional pages, if necessay N / A ADDRESS:
ADDRESS:
TELEPHONE: ()
TELEPHONE: )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED: N / A NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: | )
DATE: TIME:
ДАМ • РМ DATE: TIME: DAM 0PM
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 accident by "B-1" and the point of impact by "X". 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 → NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
7% SIDEWALK
HAVE MET THE NOON EARN STATE UPTO MONORATE AND ELEAN STEERS ELEVEN TO ERE EPT ASTO I CERTIFY (OR DECLAREY UNDER PENALT OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
WENdy Van Deventer 10-13-23
TYPE OR PRINT NAME DATE
SElE
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 Jose
#TRES Office (909) 258-3363
Cell (909) 252-0558
TIRES & WHEELS NEW & USED
260 E Foothill Blvd
Rialto, CA 92376
BRAKES, ALIGNMENTS & BALANCE WE FIX FLAT TIRES
FRENOS, ALINEACION Y BALANCEO SE ARREGLAN LLANTAS
CUSTOMER
ORDER NO. DATE 017-23
NAME
ADDRESS
TEL. —
QUANT. DESCRIPTION
PRICE AMOUNT
Nel-tire
He intal o
1245, 40 Rja"
30,000 mile
Darfun-
SUB. TOTAL
No Warranty on used tires. New tires have a six months
warranty on manufacturer defects only,unless otherwise
TAX
specified above. I agree to terms and conditions
Customer Signature _ TOTAL
1140
OUTSIDE