CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
g CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2024 JAN 29 AMII: 59
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gor. Code 59112) COLM.
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:
Henry Barklett Banks -
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 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 • 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? • YES • NO WERE PARAMEDICS AT THE SCENE? AYES • 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 THIS CLAIM: $15 million ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
CITY OF RIALTO
Item/Date: wrognful death Amount: $
Item/Date: 2021 JAN 29 AMIl Amount: S
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: RECEIVED $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (altach a dantonal pages, if necessary) NAME: unknown NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: |)
DATE: TIME DAM 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. if a city/town venicle 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.
N
WE
S
W RIALTO AVE
PARKWAY
SIDEWALK
SIGNATURE OF C/AMANT Of AĞENT Stefano
Formica 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
PRIORITY
PRIORITY
UNITED STATES
MAIL MAIL
POSTAL SERVICE ® EXPRESS®
CUSTOMER USE ONLY EJ 333 879 477 US
FROM: (PLEASE PREIT)
EXPRESS® PHONE (
FORMICA LAW GROUP
PAYMENT BY ACCOUNT (t applicable)
5900 WilShine Bird USPS° Corporate Acct. Me Federal Agency Acct. No. or Postal Servico Acct. No.
STE 2250
ORIGIN (POSTAL SERVICE USE ONLY)
Los Angeles, CA 90036
FLAT RATE Lo Day [12-Day •Mistary LIDPO
PO ZI Codo Scheduled Delivery Date
DELIVERY OPTIONS (Customer Use Only) (MMDD/YY)
ENVELOPE SIGNATURE REQUIRED Note: Tho mailer must chock the "Signature Required" box if the malor: 1) 40036 121 124 30.45 Hoquros the addressee's signature: OR 2) Purchases additional insurance; OR 3) Purchases COD service; OR -4) Purchasos Retur Receipt service. if the box is not checked, the Postal Service will leave the itom in the addresses? Dale Accepted (MNDDAY) Scheckule Delivery time Insurance Feo COD Re :
mail receptacle or other secure location without attempting to obtain the addressoo's signature on dolivery.
ONE RATE • ANY WEIGHT Delivery Options • али Et-coPl $ Ar • No Saturday Delivory (dolvored noxt business day) 1/2624 • Sunday/Holiday Delivery Required (additional fee, where availablo*) 10:30 AM Delivery Return Recolpt Foo Livo CANTE
L 10:30 AM Delivery Required (additional fee, where available*) WAM Tran Shortetion Fer *Refer to USPS.com" or local Post Office" for availability. 11:21 [3PM TO: (PLEASE PRINT)
PHONE ( -
To schedule free Package Pickup, Special Handling Fragio Sunday/Holiday Premium Fee Total Postage & Fees scan the QR code. Rialto City Clerkis office
I50 S Palm Ave
Weight Litat Rato Acceptanco Employeo Initiels
Rialto, CA 92376 30.45
DELIVERY (POSTAL SERVICE USE ONLY)
ZIP + 4° (U.S. ADDRESSES ONLY) Delivery Attempt (MM/DD/Y) Time Employco Signature CAM
• PM
• For pickup or USPS Tracking"*, visit USPS.com or call 800-222-1811. Dolivery Allompt (MMDD/YY) Timo Employeo Signaturo CAM
• $100.00 insurance included.
USPS.COM/PICKUP
LABEL 11-B, MARCH 2019 PSN 7690-02-000-9996
PEEL FROM THIS CORNER
UNITEDS
PS10001000006 EP13F July 2022
OD: 12 1/2 × 9 1/2 POSTAL SE