CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 FEB -9 PM 2: 30
TO PERSON OR PROPERTY
RECEIYCL
SITY CLLRA
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).
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:
Hares, Clara
FULL NAME -
DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
NoNe
L
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Same as atoe
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 12-09-2023 - TIME: 415 AM MAMOPM
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.
FroNT eNtry Door and Security SareeN. and Side of house.
FiremeN Made a Mistake aNd got wrongg adress When
inswering a Call. The. call was for spacé 82
3. HOW DID DAMAGE OR INJURY OCCUR?
Door broken by Forced entry, Firemen Made a
Mistake - we didnt Call for anything.
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? YES ENO
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.
Mistaken address by Firemen. DamaGe to Front door,
Screen, Door frame, and the side of the house where door bocks. also 4 Locks were broken.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 3,68.12 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 12-10-23 Amount s / 850"
Item/Date: 12-10 - 23 Amount: $ 1800.00.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $3,168.19 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hem/Date: Clara Flores B*B hock* Security Amount $ 1, 7/8.22 Item/Date: sopez Construction 1-29-24 Amount $ 1,450.50 TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 3,168-74
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Raymond Flores NAME: Clara Flores
ADDRESS:. ADDRESS:
CA. 92410 San Bernardino CA 9240
TELEPHONE: TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: - NAME:
ADDRESS:
ADDRESS:
TELEPHONE: _ ) TELEPHONE: |)
DATE: _ TIME: _ DATE:
. TIME:
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. r a citylown 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 hen 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
7 SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Clara Flores Feb,9, 2024
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
RIALTO BRETT WESTPHAL
CAPTAIN
ARSON INVESTIGATOR / TLO
FIRE
909-820-2501
RIALTO FIRE DEPARTMENT
12-09-23
(909) 820-2581
Fax (909) 421-0824 131 S. Willow Avenue
[email protected] Ríalto, CA 92376
Dec 09 - 2023
FiredeRart
Rialto, CA Potice
Brett West Phal-CaptaiN
909-820-2501
FAX 909-421-0824
Rialto Police Curtesy Notice
12-09-2023 sate 0485
PR#932313977
runtact officetoriNg
909-848-1216
at 4:15 AM On Dec. 09, 2023, my hustand, Raymond a va
mipe were awakened by loud banging on our front
door. We rushed to oar front room where a
roup of tiremen from rialto were enterino
our home! * San BerNardino 92410
They realized they had the wrong address when they
were informed we were fire, Our Sereen and front
doot were damaged beyond repair The door frame
required replacement, New door & security screen.
ONe of the repairs was started to by Lopez Construction. # The ke He removed the damaged door + Screen and put
are a New tempory temporary door and screen, the
Frame negrited a carpenter to finish the Frame and
harg bothfdoors, the cost to 1s 15 3,16878 to ka
have the frame, doo and Screen Plus hanging doors a house The house framn nes wooded repains dine to fit the metal new door.
Raymond r lures
+ wake up sometimes scared , Thinking some one is.
braking the door to down. Baymond Flore.
At night time-
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From: *B & B LOCK & SECURITY (via Clover)"
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Date: December 26. 2023 at 9:29:41 AM PST
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B & B LOCK & SECURITY
13064 CENTRAL, CHINO, CA 91710
21 0n0.501_1210
Bi lock & Soundey
B & BLOCK & SECURITY
( FOLLOW
13064 CENTRAL
CHINO, CA 91710
+1 909-591-1319
74052 $1,718.79
Subtotal $1,718.79
Total Taxes $0.00
Order total $1,718.79
Total $ 1,71879
December 21, 2023 11:35 am
Payment ID:
Order ID:
Order Employee: Gabe G.
Payment
VISA $1,718.79
Order amount $1,718.79
Cashier: Gabe G.
Show Details
PAYMENT ID:
Cashier: Gabe G.
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Clover
972772
Invoice
SHIP TO
Clara Flores ..- Ruben Ambriz
ADDRESS ADDRESS
CITY, STATE, ZIP
Sambernardino Cal. 92418
FO.B.
12-10-23
Repair dor temporarity
Parts + Labor 1,800-
$
Estimate only
8 adamss• T5000
TOTAL $ 1,800°"
Lopez Construction To 287 9/32
13274 3240 zE 198321
Invoice 91710
SOLD TO Clara Flores SHIP TO
ADDRESS ADDRESS
CITY, STATE, ZP
Bernard mo 924100 STe aP
CUSTOMER ORDER NO. TERMS FO.B. DATE
ORDERED SHIPPED PRICE UNIT AMODAY
Labor 8001
Remove & fe Place fort pook
Januar 29, 2024
ToTal $ 1450 00
& adams 5840
Member Number Statement Period Page
A
120010502 12/01/23 Thru 12/31/23 1 of 3
Arrowhead
ACCOUNT SUMMARY
credit union
00 SAVINGS $5,401.14
07 ARROWHEAD CHECKING $4,919.82
CLARA ANN FLORES
SAN BERNADINO CA 92410
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SAVINGS - ID 00 Last Year Dividends Earned: $5.85 YTD Dividends Earned: $8.13 Beneficiary(s): RAYMOND J FLORES
Beginning Balance + Deposits & Other Credits (1) - Withdrawals & Other Debits (0) = Ending Balance $5,400.45 $0.69 $0.00 $5,401.14
Date Amount New Balance Transaction Description
12/01 5,400.45 Balance Forward
12/31 0.69 5,401.14 Deposit Dividend 0. 150%
Annual Percentage Yield Earned (APYE) for 12/01/23 through 12/31/23: 0.150%.
ARROWHEAD CHECKING - ID 07 Last Year Dividends Earned: $0.31 VTD Dividends Earned: $0.00 Beneficiary(s): RAYMOND J FLORES
Beginning Balance + Deposits & Other Credits (0) - Checks (0) Other Withdrawals (5) = Ending Balance $6,930.71 $0.00 $0.00 $2,010.89 $4,919.82
Date Amount New Balance Transaction Description
12/01 6,930.71
12/11 -24.10 6,906.61 Withdrawal POS SHELL SERVICE STATION RIALTO CA 12/19 -240.00 6,666.61 Withdrawal POS RIALTO PHARMACY RIALTO CA 12/22 -1,718.79 4,947.82 Withdrawal Debit Card VISA Merch.Post:12/21 B & BLOCK & SECURITY CHINOCA 12/26 -23.00 4,924.82 Withdrawal POS SHELL SERVICE STATION RIALTO CA 12/31 -5.00 4,919.82 Withdrawal CHECKING FEE
Reporting Information for 2023:
Total Non-IRA Dividends Paid Year to Date: $ 8.13
Total Dividends Earned Year to Date: $ 8.13
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