CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2004 APR 15 AM 9: 34
TO PERSON OR PROPERTY RECEIVED
CITY CLERA
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 9237 ddress: 290 W. Rialto Ave., Rialto, CA 9237
CLAIMANT INFORMATION:
Nancy Baez
FULL NAME DATE OF BIRTH
1 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: 10/15/2023 TIME: 1:30 • AM 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.
See attached.
3. HOW DID DAMAGE OR INJURY OCCUR?
See attached.
4. WERE POLICE AT THE SCENE? YES WERE PARAMEDICS AT THE SCENE? AYES O NO
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.
See attached.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: See attached. Amount: $ over $1,000,000.00
Item/Date: See attached. Amount: $ Over $1,000,000.00
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ over $1,000,000.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: Sover $1,000,000.00
Item/Date: Amount: $ Over $1,000,000.00
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Unknown at this time NAME: Unknown at this time
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Arrowhead Regional Medical Center NAME: 20
ADDRESS: 400 N. Pepper Avenue ADDRESS:
Colton, CA 92324
TELEPHONE: ( TELEPHONE: | )
DATE: 10/15/2023 TIME: •AM 0 PM DATE: TIME: ПАМП РМ
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.
CURB Miro Way
PARKWAY
SIDEWALK
Locust Avenue
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 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Kourosh Pishnamaz 4/12/2024
TYPE OR PRINT NAME DATE
Attorney
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 The accident that is the subject of this Complaint occurred on October 15, 2023, on Miro Way west of Locust Avenue in the City of Rialto, County of San Bernardino, State of California.
At all times herein mentioned, the Miro Way and Locust Avenue intersection was owned and maintained by the City of Rialto.
At all times herein mentioned, Defendants, The City of Rialto were the owners of a Miro way and Locust Avenue intersection, involved in the traffic collision that is the subject of this Complaint.
At all times herein montioned, Plaintiff, Shannon Scott, was the operator of a motor 2a vehicle generally described as a certain 2006 Toyota 4runner Sr5 license No. PR CITY OF 15 Plaintiffs, Jeremiah Scott, Nancy Baez, and Penelope Scott, were passengers in the aforementioned 2006 Toyota Arunner Sr5. At all relevant times Plaintiff was traveling in ar RIALTO general westbound direction on Miro way in the City of Rialto and was at all times proceeding lawfully.
At all times herein mentioned, the Miro way and Locust Avenue intersection was owned and maintained by the City of Rialto. On or about October 15, 2023, at the aforementioned location, Shannon Scott got into a T-bone car accident with a vehicle owned and operated by Aaron Wyrick. Aaron Wyrick was traveling Northbound on Locust Avenue. Aaron Wyrick failed to stop at red light at the aforementioned intersection and collided into the driver's side of Shannon Scott's vehicle, subsequently causing Shannon Scott's vehicle to lose control and collide into the light pole on the aforementioned intersection. The subsequent collision ensued due to the insufficient distance between the traffic pole and the street, resulting in Shannon Scott's vehicle colliding with the light pole. Consequently, the Plaintiffs, comprising Shannon Scott, Jeremiah Scott, Nancy Baez, and Penelope Scott, sustained severe injuries from the aforementioned collision. Moreover, it is tragically noted that Nancy Baez, one of the passengers, was pregnant at the time of the accident and tragically lost her unborn child as a direct result of the collision. Defendants, and each of them, so negligently and carelessly owned, possessed, controlled, maintained, inspected, repaired, and operated the aforementioned light pole in that at said time and place. The aforesaid Defendants, and each of them, knew, or in the exercise of ordinary care should have known, of the conditions then existing, and despite such knowledge, failed to exercise reasonable care in the ownership, control, placement, and maintenance of the poles on the aforementioned street corner as to avoid the aforesaid collision.
The City is responsible for the injuries and damages under Government Code §815 et. seg.