CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 MAY - T AMI0: 16
TO PERSON OR PROPERTY
RECEIVE
CITY CLERK
1. Claims for death, injury to person, orto 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 59112). 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:
Bridese Navawo
- DATE OF BIRTH
FULL NAME/
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: 04/10/2024 TIME: 11:30 DAMOPM
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. 101 4 Pepper ave Rialto CA 92376 in ape Shopfing
cantor teino ear wasn•
3. HOW DID DAMAGE OR INJURY OCCUR?
cell Phane was not retuned by Amer atrem
As sioso u bit not karan venue
4. WERE POLICE AT THE SCENE? DIESNO WERE PARAMEDICS AT THE SCENE? DYESINO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee casing the jury rama, own 00 AC19415
ortiler m. Marrez au, zestepper never vetwic
My phane i lt was lost
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $989.99 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hemate: IPhaneLAx 4/10/24 Amount: 589.99
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $989.99 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount s989.99
prane 14 plus
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: F00L
NAME:
ADDRESS: 3 N. 215+ san Berrevoino
ADDRESS:
TELEPHONE: |) TELEPHONE: ( )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME: _
ADDRESS: ADDRESS:
TELEPHONE: ) TELEPHONE: L)
DATE: TIME: • AM • PM
DATE: - TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
Of ai ent by and by along hours he toilers or dian heart or see, clung NORTH, EAST, THAN WE directions. Indicate place 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.
CURE
PARKWAY
Hooping SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU I CERTIFY OR DECI ARETTINNER DENAI TV OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
04|29/24
TYPE OR PRINT MAME DATE
Myself
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 T••Mobile®
Receipt
Store Customer Date: 10-26-2022 20:24:19
T-MOBILE 8269 Account #:
9400 FIRESTONE BLVD Register#: 17
DOWNEY, CA, 90241-5504 Trans #: 2928
(562) 803-1082
Sales Rep #: ****758
Transaction Details
SKU Description aly @Price Downie Today
Installment Purchases
000000194253372387 APL IPHONE 14 PLUS 128G PUR KIT 1 @ 899.99 $0.00 T Mobile Number:
Activation
Not Discount Eligible
TAX 899.99 @ 10.0% $90.00
Sale Amount $899.99
Installment Purchases Down Payment $0.00
TAX 899.99 @ 10.0% $90.00
Installment Purchases Total $989.99
Installment Purchases Down Payment Total $90.00
SKU Description Qty @Price Extension
Purchases Not on Installment
ZZZ260R070 TRIPLESIM PLUG 64K TO UICC [email protected] $0.00 T
Mobile Number :
Activation
Not Discount Eligible
TAX 0.0 @ 10.0% $0.00
ONSUPCHG ASSISTED SUPPORT 1 @ 35.00 $35.00N
Mobile Number:
Not Discount Eligible
ONSUPCHG ASSISTED SUPPORT 1 @ 35.00 $35.00N
Mobile Number
Not Discount Eligible
TRIPLESIM PLUG 64K TMO UICC [email protected] $0.00 T
ZZZ260R070
Mobile Number :
Activation
Not Discount Eligible
TAX 0.0 @ 10.0% $0.00
ONSUPCHG ASSISTED SUPPORT 1 @ 35.00 $35.00N
Mobile Number:
Not Discount Eligible
Sale Amount $105.00
TAX 0.0 @ 0.0% $0.00
Purchases Not on Installment Total $105.00