CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 MAR - 4 AMII: 09
TO PERSON OR PROPERTY RECEIVED
CITY CLEAR
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). 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 9237
CLAIMANT INFORMATION:
Silvano Ulloa Prieto
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 Rafii & Associates, P.C.
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
9100 Wilshire Blvd. #465E, Beverly Hills, CA 90212
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 09/05/2023 TIME: 2:00 • AM IX PM
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.
Foothill and Terrace Road, San Bernardino, CA
34.106604, - 117.336916
3. HOW DID DAMAGE OR INJURY OCCUR?
Silvano Ulloa Prieto was walking eastbound on Foothill Street on the southside of street as he approached Terrace Road he slipped and fell on sidewalk due to the conditions, lack of maintenance and trash.
4. WERE POLICE AT THE SCENE? •YES 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.
The City of Rialto failed its duty to maintain the sidewalk in such condition that the sidewalk will not endanger persons and maintain it in a condition which will not interfere with the public convenience of its use.
The City of Rialto negligently designed the sidewalk and created a dangerous condition.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 300,000 to date HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $- ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $_
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: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
Valley Healthcare Center NAME: Dignity Health -Community Hospital of SB NAME:
ADDRESS: 1680 N. Waterman Avenue ADDRESS: 1805 Medical Center Drive San Bernardino, CA 92404 San Bernardino, CA 92411
TELEPHONE: (909 886-5291 TELEPHONE: (909,887-6333
DATE: TIME. • AM • PM DATE: TIME: •AM D PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehide 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.
CURB
PARKWAY
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. - ARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OR CLAIMANT OR, AGENT
Alan Marco, Eg. | Rati Asocinter 2.28.24
YPE OR PRINT NAM
Attones
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
OU
TF
6703
20214 MAR -4 AHI: 09
CITY OF RIALTO
CITY OF RIALTO
2021 MAR - 4 AMII: 10
RECEIVEL
CITY CLERK
dEx® -- DIALTO
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ORIGIN ID:BABA (310) 777-7877 SHIP DATE: 29FEB24
ACCOUNTING ACTWGT: 0.50 LB
RAFII & ASSOCIATES, P.C. CAD: 259846341/INET4535
9100 WILSHIRE BLVD
SUITE 465E
BEVERLY HILLS, CA 90212 BILL SENDER
UNITED STATES US.
dEx First Overnight® TO RIALTO CITY CLERKS
RIALTO CITY CLERKS OFFICE
150 S. PALM AVE.
RIALTO CA 92376
(310) 771-7877
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147918 REV 3/21 Ш
F FedEx FRI - 01 MAR 8:00A
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02011 7753 7226 4803 FIRST OVERNIGHT
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03.04 92376g
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#4692612 02/29 583J6/194B/9AE3
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147918 REV 3)