CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTE
CLAIM FOR DAMAGES 2024 FEB 22 AMIO: 56
TO PERSON OR PROPERTY
RECEIVEL
CITY
1. Claims for death, injury to person, or to personal property must be filed not lafer 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
• 4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mal t605 Pain ANo, Ral A 32376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Daniel mauricia
FULL NAME DATE OF BIRTH / -
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 1 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):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: August 14, 2021 TIME: 6:00 an #AMOPM
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. 263 w. Jackson Street Rialte California in ms
rousing while hey where molesting he and doing
Sexual contact tome
3. HOW DID DAMAGE OR INJURY OCCUR?
his and older quer weighted pouded huge
guy doing Sexual Cantact to me every dal
terrifine
4. WERE POLICE AT THE SCENE? DYES DINO
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.
Rialte cheat and it was rialte pelice depanied
filled a clan about having
нет pay me me property back
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ 84 HOW WAS THE ARCE AMOUN COME i is or li, api sina, to seath as nates. amount of DAMAGES INCURRED TO DATE:
Hem/Date: During year 2021-and 2623 Amount: $ 8,684
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
58,684
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 2021-2023 Amount: $ 8, 6801
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Daniel Mauricia NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: 'NA NAME:
ADDRESS: ADDRESS:
TELEPHONE: L 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 comers.
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 X
PARKWAY
SIDEWALK Y
in public places and
in city bises even at work
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
Daniel maurici, Feb. 22-2024
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 2024 FEB 22 CITY OF RIALTO
RECEIVLI ANIO: 57
CITY CLERK
8:27 • =96
LOUIS VUITTON
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2821 FEB 22 AM16 57 CIT Y OFRIAL NO
CIT
OF
2024 TRIALTO
22 AM 10: 57
102.
CLE
70% FEB 22 AN ID CITY OF RIALTO
LOUIS V.