CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
СІТУ CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2024 APR 10 PM12:21
RECEIVED
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurience (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: 150S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Jaedin Sims
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):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 03/04/2024 10:30 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.
The accident occured on Locust and lowell
3. HOW DID DAMAGE OR INJURY OCCUR?
I was driving down the street and I hit a pot hole.
4. WERE POLICE AT THE SCENE? EYES ENO WERE PARAMEDICS AT THE SCENE? YES NO . WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/towr mployee causing the injury or damage, if known.
The pot hole in Rialto Off of locust and lowell
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 155.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: _ Bent rim and Blown tire (used tire) Amount: $ /55.00 Item/Date:
Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 155.00 ESTIMATED PROSPECTIVE DAMES AS FAR AS KNOWN: Hem/Date: Rim and Tire (Used tire) Amount: $_/ SS.00
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: Jahlil Avers
NAME: _
ADDRESS:
- ADDRESS:
TELEPHONE:
TELEPHONE: (
2024 APR 10 PM 2:21 CITY OF RIALI
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: — N/A
NAME:
ADDRESS: ADDRESS:
TELEPHONE: (
TELEPHONE: | )
DATE: TIME: • Ам 0 РМ 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 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.
Lowell Locustcure Xpot hole
PARKWAY
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 THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE LGEATIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. -
SIGNATURE OF CLAIMANT OR AGENT
Jaedin I Sims 03/27/24
TYPE OR PRINT NAME DATE
Self
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF AFALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 Arrow TIRE & WHEEL
6183 SIERRA AVE. BLDG. 1 • FoNTANA, CA 92336
[email protected]
(909) 349-1746 BAR#230081
Jaedin Sims PA3-5-24
ADDRESS
CITY STATE ZIP
E-MAIL ADDRESS
1097-4878
MAKEY MODEL Cord MILEAGE
QTY. DESCRIPTION/SERVICE PARTS LABOR AMOUNT
Wheel Repair 100.-
used tire 55=
Exp. V-
C/C#
Wheel Alignment
Mount & Dismount
Tire Disposal Fee
tion Stems
Computer Balance
- MALE a may be requirec after work has started. After the work has staned, worn or damaged parts which Tris estimate is based on our inspection at this time and does not cover additional parts or labor which are not evident on tast inspecton may be discovered Trus estimate cannot cover such contingencies SUB- 155.- in cases where additional won. is deemed necessary Customer authonzation will be assured pror to TOTAL TREATM commencement ot that additional work. Trus estimate expires 15 days from date. I hereby authorize the above work to be done along with the necessary materal and hereby grant you and/or your employees permission to operate the vetedle herein deserbed on streets, highways or elsewhere for the purpose insure the amount of repairs. Dealer not responsible for unavailability of parts or delays in parts of testing and/or inspection. An express mechanics len is hereby acknowiedged on above vehicie to TAX gment:
of fire, teh or any other cause beyond our control shipments beyond dealers control not for loss or damage to vehicle or articies left in vehicle in case TOTAL
Repairs Authorized By
ift
LASER TREATMENTS
Tubular
Steel inc.
2750 N. LOCUST AVE
LOWELL 1900
OF FILING
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909-484-8259
NOTICE OF FILING