CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 1024 APR -3 PM 3: 22
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 59112) Y CLERK
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:
Rialto City Clerk's Office
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
TeRRi BrooKs
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 1909 459-9412
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 2nd, 2024 - TIME: 4:15
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.
Locust Street / RiveRside Auc
On Locust right after you pass Casa Eirende Drive
3. HOW DID DAMAGE OR INJURY OCCUR?
Pot holes in the street as you go South on Lecust towerds Castalia street.
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? • YES /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.
Potholes - Wanellythe city is good sbout-filling the holes quickly.
This street also has & leek that the city is currently eddressing.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ |45.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: March 2nd, 2024 Amount: $ 145.00
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 145.00 $.
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: NIA NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( ) TELEPHONE: ( )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: -N/ A NAME:
ADDRESS: ADDRESS: _
TELEPHONE: ( TELEPHONE: | )
DATE: TIME: DATE: _TIME: • AM • PM
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
PARKWAY
7. 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. 1 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
0 413/2024
TERRi BROOKS
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 - 150 S. PALM AVE., RIALTO, CA 92376
Certified Auto Care INVOICE
1201 E. Foothill Bivd 44715
Upland, CA. 91786 Org. Est. # 081780
Phone: 909-949-1311 Fax: 909-920-9181
AR # AE2105
Complete Auto Repair PA # CAL0002482*
INVOICE Printed Date: 03/14/2024 Work Completed: 03/14/2024 BROOKS, GRGORY 2010 Mercedes-Benz - E350 - 3.5L, V6 (213CI) VIN (Not Availabl Lic # : Odometer In : 159421
VIN#:
Part Description / Number Qty Sale Ext Labor Description Ext WHEEL REPAIR LEFT REAR 125.00
Mount & Wheel Balance 1 wheels 20.00
Remove wheels from vehicle. Inspect brakes. Computer spin balance. Reinstall wheels to vehicle and torque lug nuts to manufacturer's specifications
Org. Estimate 145.00 Revisions 0.00 Current Estimate 145.00 Labor: 20.00 Parts: 0.00
Sublet: 125.00
SubTotal: 145.00
Tax: 0.00
Total: 145.00
Bal Due: $0.00
[Payments - Visa - $145.00]
Vehicle Received: 3/14/2024 Customer Number : 15496
Signature. Date.