CITY CLERKS DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 FEB 29 AMI1: 42
TO PERSON OR PROPERTY RECEIVEL
CITY CLERK
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 §9112).
2. Claims for damages to real property must be filed not later than one (1) year after the occumence (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:
Stephen Robert Gilson
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
02|23|24 4:50
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: TIME:
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.
Gang an Pepper Aur SB befure Rialto Ave intersection there was a huge pothole in the left lane.
Because there was cars on both the left turning lane and right lane, I was unable to avard making contact with the puthale poppiry both passänger side tires and damaging both rims
3. HOW DID DAMAGE OR INJURY OCCUR?
By driving over a huge pottste
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? • YES ANO
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.
City of Rialto
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,177.20 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 02/23/24: Car tires and rims Amount: $ 1,027.20 Item/Date: 02\23/24: tow truck to get car back hom Amount: $ 150.00 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1,177.20 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 02/23 24= Cartres and rims Amount: $ 1,027.20 Item/Date: 02\23/24: tow truck costs Amount: $ 150.00
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 1,177.20
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Briana Gilson: daushter was in car NAME:
ADDRESS: 185 Manzanitast ADDRESS:
Bloomingtun. CP 92316
TELEPHONE: (714) 489-1160 TELEPHONE: ()
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: |)
DATE: TIME: ПАМ • РМ 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 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 Fust pothole
Rialto Are West y
PARKWAY
7 SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU RE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Stephen Gilson 02128/24
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 167 W San Bernardino Ave Store: 579
/ires LES SCHWAR Rialto, CA 92376 Quote: 57900205103
(909) 546-3405 Salesperson: Gregory RM
ARD 303202
Customer Information Vehicle Information
Customer ID: E1-549179 Vehicle: 2018 AUDI A3
Name: STEPHEN GILSON Color:
Address: Mileage:
City, State, Zip: , CA License:
Phone:
Les Schwab Quote
Qty Product Code Product Description Pricelea FET Amount 2 845468 17X8 5-112 RETRIBUTION 459 $202.99 $0.00 $405.98 2 123558 CHROME VALVE STEM $8.99 $0.00 $17.98
2 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00 $0.00 2 13718 WHEEL SPIN BALANCE $16.99 $0.00 $33.98
2 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $15.98 2 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $5.98
1041789 225/45R-17 91V ROAD CONTROL 2 $175.99 $0.00 $351.98 15814 AL7 4-WHEEL ALIGNMENT W/SHIMS $0.00 $0.00 $0.00
1 123308 4 WHEEL ALIGNMENT - DOMESTIC/IMPORT CARS $129.99 $0.00 $129.99 (SHIMS INCLUDED)
Sales Tax: $61.83
Tire Fee: $3.50
Quotation Total: $1,027.20
2024 FEB 29 CITY OF RIALTO
AMII: 44
* indicates sale price
For more information on our products and services, visit www.LesSchwab.com.
Prices good for 30 days, excluding promotions. Quote Expires on 03-25-2024.
Quote Date/Time: 02-24-2024 09:21 AM Page 1 of 1
CITY OF RIALTO
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CITY OF RIALTE
2024 FEB 29 AMI: 43
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CITY OF RIALTO
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CITY OF RIALTO
2024 FEB 29 AM11: 43
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C002
RIALTO CITY CLERK'S OFFICE
150 S PALM AVE
RIALTO CA 92376-6406
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