CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES
2021 JAN -2 AMII: 33
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).
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:
Cheval
FULL NAME DATE OF BIRTH
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): Icultane Ca 92334
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 10/60/23 TIME: 2:45 • AM MPM
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.
My risidence Tautarla Ca 92336
M14 Camara (Sarurity Canera) was destroyd
Rialte PD TeaM It was in the upper
3. HOW DID DAMAGE OR INJURY OCCUR?
SWAT/Rialto PD. Swatched down Whi
Security Camara Canar* Cam Claim # Provided by
4. WERE POLICE AT THE SCENE? DYES • NO WERE PARAMEDICS AT THE SCENE? •YESONO
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,
SINAT Rialto Claim # Provided by
law ENtarcenENt 9323113810
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 4/50 °0 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Security Camara 10/60/23 450=
Item/Date: _ Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 4150°° ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Iter/Date: Szcuritu amera Amount: $ 450°
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $_ 2150°
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Carlos A RaMIREz NAME:
ADDRESS: Rualto P.D ADDRESS:
# For Claim: 932311386 Provide by MR. RaMIrez
TELEPHONE: TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: L TELEPHONE: | )
DATE: TIME: DATE: TIME: ПАМ • РМ
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.
CURB
PARKWAY
7. SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREE; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BENEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I DESTIC INDREI ADEL HAIED DEAl THAN An HINU THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLÁIMANT OR AGENT
aTa la haval 112/24
TYPE OR PRINT NAME
22tt
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