CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
•
CLAIM FOR DAMAGES 2024 FEB 26 PM 1: 54
TO PERSON OR PROPERTY
RECEIVED
DITY CLERK
1. Claims for death, injury to person, orto 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:
Soledad García
FULL NAME , DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. i a/ CA 92377
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: 2-20-24 TIME: 10:00 LAM OPM
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. south bound Locust Between & fersimon st
and Lowell - on Locust Ave •
All the street backst sour by bette, matte to se bates. - E lineard Sia hales"
3. HOW DID DAMAGE OR INJURY OCCUR? The Street was
Holes damage Motive right side. see picturer
the holes were already wettes it taek to take Pictures of holes lix yia
4. WERE POLICE AT THE SCENE? • YESTINO 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.
a representative told me that I need to submit pictures with the clain and whan I went back onthe same day
to take picteves, Bp 4:30 Any Boothe loles were Dafready Patched.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 200— HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
lem Date: damoge fixed 0-2-22-24 200 -
Amount: $.
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 200- ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hemate: Damage fixed On 2-22.24 Amount: $_ 200 -
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: Ameca tires
NAME:
ADDRESS: {7814 Footh BLU¢ ADDRESS: _
antana 4 92335
TELEPHONE: 904) 350-137 3 TELEPHONE: )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME: -
ADDRESS:
ADDRESS:
TELEPHONE: TELEPHONE: | )
DATE: TIME: LAM LPM TIME:
DATE: •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 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 BYTHE CLAIMANT.
Saxe
CURB
Low'ell
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 HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
ICERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Soledad Garcia 2-22-24
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
AMECA TIRES
909.350.1373
NEW & USED TIRES
17814 FOOTHILL BLVD. - FONTANA, CA 92335
• SERVICE • WILL CALL
• INSTALL • DELIVER 152-22-202
[MAKE hondy
soledad Garcia MODE ACCOrd 2015
SERIAL
AYES
NEW TIRE WARRANTY ONO MILEAGE:
USED TIRE: NO WARRANTY DAYS: 60h
IMPORTANT: MUST HAVE RECEIPT FOR VALID WARRANTY
QTY. DESCRIPTION AMOUNT TOTAL
I New Tire 235-45 18 #2004200
Wheel Repair
Used Tires
Rotation
Mounting
Patching
Valve Stem Plugs
Tire Fee
(Used Tire No Warranty)
Total Material
USED TIRES Tax
DO NOT COVER
ROAD DAMAGES. Total Labor
THANK YOU! Disposal Fee
3 4 ¡HABLAMOS ESPAÑOLI Total AmountA t
IECA TIRES: Do not guarantee used tires or used wheels. no refunds or exchanges. Custon possible with a new tire. AMECA TIRES is not responsible for lost articles, i.e. Center caps, hub caps attache wheels, spacers and/or loose luanuts, etc.: as well as not responsible for damage or inconvenience any use tire may cause you and/or your vehicle.
Customer Signature: - Date:
VISAGE DOVER LAS Thank You For Your Business!
HANDISE