CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTE
CLAIM FOR DAMAGES 2024 MAR 19 PM 3: 51
TO PERSON OR PROPERTY
ONY CLERE RECEIVEL
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: 290W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Natalie Duarte
-
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: March 14,2024 TIME: 5:20 MAMOPM
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.
W. Rialto Ave SiN Meridian Ale. The Pothole was located Prepare Detween Meridlan Ave and the rain road
3. HOW DID DAMAGE OR INJURY OCCUR?
1 was coming back from dropping of my boutriend at work at 5am in colton I was on w. Riaito Are to ao back home when the pothole damaged my tire it now has a bump.
4. WERE POLICE AT THE SCENE? YES 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.
1claim the citu of Rialto responsible tor damagina mu tire due to the immense potholes that are tonna near the
raikoad track on w. Rialto Ave near the end of reossrection
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $120 Meridian Ave.
HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 319/24 Tire / Balance / Mounting Amount: $ 95 Item/Date: 3/19/24 Tire Amount: $ 120
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 140 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 3/19/24 New Tire Amount: $ 120
Hem/Date: Mounting & Balance needed Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 140
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
NAME:,
ADDRESS: ADDRESS:
TELEPHONE: ) TELEPHONE: _)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE:
DATE: TIME: • AM • PM 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 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. /lot of Potholel
Dirt
N. Ria CURB AVe
Track
PARKWAY
Ve SIDEWALK
vi
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 CERTIEY IOR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Natalie Quarte 0/14/24
TYPE OR PRINT NAME
Selt
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 Pothole that damaged tire
Damage to Vehicle: Tire
HAILAND
DOT TEVE
VARGAS
Tires & Whooks
951-640-0352
630 W. Rialto Ave., #A-7, Rialto, CA 92376
CUSTOMER
ORDER NO. DATE 3-19-24
NAME
ADDRESS
PHONE #
SOLD BY CASH
C.O.D CHARGE
ON ACCT MDSE RETD PAID OUT
QUAN. DESCRIPTION
PRICE AMOUNT
TIRE(S) 010
USED TIRE(S)
WHEEL(S
USED WHEEL
BALANCE - MOUNTING
BRAKES
DISPOSAL FEES
FIX FLAT
LUG NUTS)
VALVE STEM
MANUFACTURER - WARRANTY
All sales are final warranty is for the treadlife on any kind of defect on tires limited manufactures warranty unless road hazard insurance is obtained. LABOR Tires are prorated according to use. Not Responsible for tire clearance or stripped lugs or broken studs. If you are satisfied tell others, if not tell us SUBTOTAL With us you always have a friend. No Waran y on used fre purchase, TAX SALES o se admiten devoluciones, las llantas estan garantizadas por qualqu fecto solo en uso normal recargo por uso de llanta, si compra segu TOTAL seguridad, su familia se lo merese. Gracias por su compra. Con nosotros esta le cubrira contra cualquier cosa de por vida de la llanta. Maneje con DEPOSIT siempre tiene un amigo. No Garantia en Liantas Usadas.
BALANCE
All claims and returned goods MUST be accompanied by this bill.
No.# 1163
Alignment & Balance • Brakes
TIRES & WHEELS Shocks • Rims Repair
RODRIGUEZZ
735 W. Rialto Ave • Ste D • Rialto, CA 92376
909.917-7547
909.917.7547
Free Alignment when you buy 4 new tires
CUSTOMER
ORDER NO. _DATE 3.19-24
NAME: Natalie
ADDRESS:
PHONE:
SOLD BY CASH C.O.D CHARGE ON ACCT MDSE RETD PAID OUT
QUAN DESCRIPTION PRICE AMOUNT
TIRE(S) NEU 1L5•40-1k 20
USED TIRE(S)
WHEEL(S)
USED WHEEL
BALANCE-MOUNTING
BRAKES
DISPOSAL FEES
FIX FLAT
LUG NUT(S)
VALVE STEM
MANUFACTURER - WARRANTY
All sales are final warranty is for the treadslife on and kind of defect on tire: LABOR mited manufactures warranty unless road hazard insurance is obtained Tires are prorated according to use. Not Responsible for tire clearance or SUBTOTAL stripped lugs or broken studs. If you are satisfied tell others, if not tell us Drive with confidence your family deserves it thank-you for you purchase, TAX SALES 20:
with us you'll always have a friend. No warranty on used tire.
No se admiten devoluciones, las llantas estan garantizadas por cualquier TOTAL defecto solo en uso normal recargo por uso de llanta, si compra seguro esta le cubrira contra culquier cosa de por vida de la llanta. Maneie con DEPOSIT seguridad, su familia se lo merece. Gracias por su compra. Con nosotros siempre tiene un amigo. No Garantia en llantas usadas. BALANCE All claims and returned good MUST be accompanied by this bill