CITY CLERKS DATE STAMP
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 202: JAN 23 PM 3: 27
RECENCO
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 S9V1.2X CLERK
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:
Patricia E. Schwengler
-
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/a ( N/a
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE See above
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _ 01/02/2024 TIME: 3:30
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.
North on Alder Avenue, between Walnut and Miro, 1400 Block
3. HOW DID DAMAGE OR INJURY OCCUR?
Ran over pleces of metal that were all over the road
Metal cut rear, drivers side, tire.
4. WERE POLICE AT THE SCENE? •YES KINO 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.
metal in road caused severe damage to my tire
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 148.15 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: _ Costco receipt 1/3/24 Amount: $ 148.15
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $. 148.15 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: CITY OF RIALT Amount: S
Item/Date:
1826. JAN 23 PM 3: Amount: s
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 148.15
RECE
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information attack aditional pages, if necessary) NAME: matthew Schwengler NAME:
ADDRESS: ADDRESS:_
Rialto, Ca 92377
TELEPHONE: TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: |)
DATE: _TIME: •AM • PM DATE: _TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
Forall 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. -Alder Ave Redian → N
Selin
PARKWAY
SIDEWALK
VE
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 HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Patricia F Schwongler 1/3/2024
TYPE OR PRINT, NAME DATE
Velf
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150S. PALM AVE., RIALTO, CA 92376 COSTCO Date: 01/03/24 Invoice #: 6270253711
Time In: 13:44:21
-TIRE CENTER MEMBER PURCHASE INVOICE Membership#:
MEMBER INFORMATION VEHICLE INFORMATION
PATRICIA SCHWENGLER CITY OF R 2012 Hyundai Santa Fe Limited 2024 JAN 23 Blue License:
Odometer:
RECEIV Wheel Torque: 80
CITY CL Air Pressure: Front: 33
Rear: 33
ITEM# DESCRIPTION Qty SLIP PRINT
1166528 ADVANTAGE T/A SPORT LT
ALL WEATHER TIRE
235/60R18 103V BSW
MSPN 42377
60,000 Mile Warranty SHOP ÖRDE
6850333 BFGoodrich No Charge Installation 1
504595 1166528 235/60R18
Nitrogen Tire Inflation 4
VOLO
7023 CA STATE TIR
Tire Disposal Fee 1
1166529 255/6018
866632 TPMS Service Pack Generic CA STATE TIE
1 TIRE DEPOSL
1166528 Road Hazard Warranty SERVICE FY G
SUBTOTAL
Costco #627 TOTAL
16505 Sierra Lakes Pkwy MGR GYR
Fontana, CA 92336
909-770-5630
21.25 BAR # APD 272344 Tomi am
TOTAL HUMBER
909-581 1709
CASHI:
01/03/29
***SPECIAL ORDER***
9200062702537117
NOTES:
See Additional Notes...
*Inflation and Torque specifications are recommended by Manufacturer. _ Best to Spare
Static _ Dynamic • EDWIN M
- -
Blackwall Whitewall Sales Person
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CITY OF RIALTE
2024 JAN 23 PM 3:28
CITY RECEIVEL
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