CITY CLERK'S DATE STAMP
CITY OF RIALTO
CALIA,
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2024 MAR 25 AMII: 08
RECEIVE
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months aller the occurrence (Gov Code $911 2) IT Y CL CRE
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 92376
CLAIMANT INFORMATION:
Myesha Cummings
FULL NAME DATE OF BIRTH
HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
L
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: _ 07/15/2023 TIME: 3:00 am
D AM O 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.
The civil rights violation took place at the claimant's home located at Rialto CA 92376.
3. HOW DID DAMAGE OR INJURY OCCUR?
Ms. Cummings wake up in the aary morning of July 15, 2023 to her ex-hushand hitting and yelling at her. in an attemt to flee, she want into the bathroom. and closed the door. Her ex-husband, Marcus Johnson, knocked the door off the hinges and tackled her. He pinned her onto the bed and Ms. Cummings used herlegs to push Johnsomoff. At this point, Cummings urinated on herself due to the incident. Cummings was yelling for her children to call the police.
Once Johnson heard the children, he let Cummings off the bed. Johnson went outside and laid prone on the ground with his hands away from his body to 4W20E POLE AT THE SCENE? ZI YES CONO WERE PARAMEDICS AT THE SCENE? DYES CONO
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 is responsible for the injury because the officers fabricated the probable cause and reasonable suspicion that a crime had occurred and that Ms. Cummings was the perpetrator of the crime. The officers fabricated the probable cause and failed to evaluate and property document the evidence thereby resulting in the false arrest and detention of Ms.
Cummings in violation of het state and federal constitutional rights. The officers further improperly documented Me. Cummings' statements thus creating a false report in order to justify their illegal detention and arrest.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 250,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Actual harm including confinement, neglect, and abuse. 50,000 Item/Date: _ Amount: $
Item/Date: Emotional harm including confinement, neglect, and abuse. Amount: $ 200,000 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $. 250,000 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: TBD TBD
Amount: $_
Item/Date: TBD Amount: $_ TBD
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: TBD
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Tyrell Roberson NAME: Ariel Johnson
ADDRESS: ADDRESS:
TELEPHONE: ( ) TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
Arrowhead Regional Medical Center Kaiser
NAME: NAME:
ADDRESS 400N. Pepper Ave Colton, CA ADDRESS: Virtual appointment TELEPHONE: TELEPHONE: [ )
DATE:7 / 1 5 / 2 3 TIME: _ •AM • PM DATE: 7/17/23
TIME: • AM 0PM
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 BY THE CLAIMANT. 2024 MA CITY OF
CITY tULI
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CURB
71F PARKWAY AMII: 08 RIALTO
SIDEWALK
HAVE READ THE FOREGOING GLAIM 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 TRUE I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
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 - 150S. PALM AVE., RIALTO, CA 92376 s. Retail -: U.S. POSTAGE PAID
FOM LETTER
LA PUENTE, GA 91747
MAR 22, 2024-
POSTAL SERVICE
92376 $0.68
RDC 99 R2304N117983-25
CITY OF RIALTO 207L MAR 25 AMII: 0 CITY CLEAT Rialto City Clerk's frie 150 8. Palm Are.
Rialto, CH 92374
92376-648799
Kings Justice Law
280 S. Beverly Dr. PA
Beverly Hilb, CA 90212