CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2021 JAN 29 PM12: 00
TO PERSON OR PROPERTY
RECCIVEL
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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
_Dorothy L McDonald
- DATE OF BIRTH
FULL NAME
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
L
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Formica Law Group
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 5900 Wilshire Bld Ste 2250 Los Angeles, CA 90036
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 08/13/2023 TIME: 04:37 *AM 0 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. 805 W Rialto Ave Rialto, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Mr. Banks was a pedestrian struck by a vehicle (two or more).
4. WERE POLICE AT THE SCENE? X 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.
Individuals including members of the Rialto Police Department negligently and carelessly and in violation of police department protocol struck and killed decedent, De Angelo Banks. Rialto Police Department negligently and carelessly and in violation of police department protocol failed to follow proper procedure including preservation of evidence and camera footage available of the incident, as well as investigation protocol surrounding potential causes of the fatality. As a result of the negligence and breach of police conduct standards of the Rialto Police Department and/or possibly others, claimant's decedent heirs suffer and will continue to suffer damages as a result of his wrongful death.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_15 million HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: wrongful death Amount: $ 15 million
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THISCLAIM RIALTO $15 million ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: wrognful death 2024 JAN 29 PH 12m@gnt: $.
Item/Date: LECEIVED Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: CITY CLERK $
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 DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L 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. 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 vehicl 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.
N
WE
S
CURB O
WRIALTO AVE
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 REN ATE NON MY IN ATON AND RUE, AND AS TO THOSE MATTER BEEVE THEM TOBE TRUE.
SIGNATURE OF CLAIMANT OR AGENT
Stepand • Fornica 1/25/24
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 Rotan U.S. POSTAGE PAID
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