CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2024 MAY - 2 AMII: 4
RECEIVE iN
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). OTTY CLERK
2. Claims for damages to real property must be fled 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: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Thomas L. Burns
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 25950 Acero, Suite 200
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Mission Viejo, CA 92691
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 2/28/2024 TIME: _ 5:20
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. 1605 S. Riverside Ave., Rialto, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Mr. Thomas L. Burns was walking south on the north bound sidewalk of S. Riverside Ave.
As Mr. Burns walked passed Panda Express, he tripped over a lip on the sidewalk that protruded a few inches above the sidewalk. Mr. Burns fell forward onto the sidewalk.
4. WERE POLICE AT THE SCENE? • YES •NO WERE PARAMEDICS AT THE SCENE? DYES D 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.
This injury was caused as a result of the protrusion of the concrete panel on the sidewalk, which caused the sidewalk to be uneven. The sidewalk is maintained by the City of Rialto.
1 mittion dollars.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ Treatment is ongoing HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE: 2/28/2024 to present.
Item/Date: Medical treatment is still ongoing Amount: $ 1,000,000.00 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: 2/28/2024 to present Item/Date: Medical treatment is still ongoing Amount: $ 1,000,000.00 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: NAME:
ADDRESS: ADDRESS:
TELEPHONE: C TELEPHONE: [
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:_Arrowhead Regional Medical Center NAME: City of Rialto Ambulance Service ADDRESS: 400 N. Pepper Ave. ADDRESS: P.O. Box 269110
Colton, CA 92324 Sacramento, CA 95826
TELEPHONE: (909 580-1000 TELEPHONE: (866 385-6552
DATE: 2/28/2024 TIME: 6:00 LAM EX PM DATE: 6:00 TIME: • AM IX 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. 2024 MAT
Value Ctr. DITY
CURB S. Riverside -2 CITY OF RIALTG
CLERK
PARKWAY
AMI: 41
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 (E) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Brian Banner, Esq. 4/12/2024
TYPE OR PRINT NAME DATE
Legal Counsel
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150S. PALM AVE., RIALTO, CA 92376 PS00001000012 USPS.COM/PICKUP scan the QR code. To schedule free Package Pickup. ONE RATE ANY WEIGHT ENVELOPE FLAT RATE MAIL PRIORITY PRESS FIRMLY TO S OLI
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04/24/2024
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Banner Attorneys
25950 Acero Suite 200
Mission Viejo CA 92691-7932
ZHOL
SHIP Rialto City-Clerk's Office
TO: 2924 MAY -2
150 S Palm Ave
Rialto CA 92376-6406 CILY OF RIALTO
AM 1!: 41
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