CITY OF RIALTO
LIABILITY 2024 APR 17 STY OF RIAL TO
CLAIM FOR DAMAGES PM |: 16
TO PERSON OR PROPERTY RECEIVEO
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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave Pi-* A 92376
CLAIMANT INFORMATION:
Thomas L. Burns
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
L
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: 2/28/2024 - TIME: 5:20 П АМ ГРМ
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? •YES 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.
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:
Item/Date: Medical treatment is still ongoing Amount: $ Item/Date: Amount: $.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY OF RIALIE Item/Date: Medical treatment is still ongoing 202, APR /7 Item/Date: _
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: RECEIP $.
CITY
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME: _
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: 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 • AM XPM DATE: 6:00 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.
Value Ctr.
CURB S. Riverside
PARKWAY
711 x 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. ..... 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 - 150 S. PALM AVE., RIALTO, CA 92376
INCIDENT REPORT - ADDITIONAL PERSONS
Agency Name: ORI#: Report Date/Time: OCA#:
RIALTO POLICE DEPARTMENT 03/08/2024 13:52:54
V Person Phone: Cell Phone:
Business P9912 CAPTAIN MEREDITH 909-374-2772 Paper an
Address (Street, Apt., City, State, Zip):
RIALTO FIRE DEPARTMENT
Involvement Type (Person): Victim Type (Business): Domestic r LEOKA Activity: LEOKA Assighment:
OTHER Violence
Occupation: Employer: Employer Address: Employer Phone:? 7 OTHER GOVERNMEN RIALTO FIRE
SERVICI
Relationship to Offender: DOB: Age: Sex: Height: Weight: Build: Complexion: •Eye Color:
License (#, Class, State): Related Offense(s): Hair Color: Hair Length: 'Hair Style:
Race: Ethnicity SSN:
Vite NON-HISPANIC
Clothing Description: NCIC#: State ID#: Facial Hair: Speech: Teeth:
Body Markings (Type, Location, Description): Solicited/Offered: Injury Type:
• Minor Injuries Unconscious
Internal Injuries Teeth Injury
Suspect Forced Victim: Primary Action: Suspect Force: I Lacerations Bone Injury • Other Injuries • None
Person Phone: Cell Phone:
Name:
| Business THOMAS BURNS
Address (Street, Apt., City, State, Zip): Pager:
Victim Type (Business): Domestic F LEOKA Activity: LEOKA Assignment:
Involvement Type (Person):
Violence
OTHER
Occupation: Employer: Employer Address: Employer Phone:
Age: Sex: Height: T Weight: Build: Complexion: Eye Color:
Relationship to Offender:
09/3/1958 M 510 250 HEAVY
SSN: License (#. Class, State): Related Offense(s): Hair Color: Hair Length: Hair Style:
Race: Ethnicity:
White NON-HISPANIC C CA
NCIC#: State ID # Facial Hair: Speech: Teeth:
Clothing Description:
Body Markings (Type, Location, Description): Solicited/Offered: Injury Type:
• Minor Injuries Unconscious
• Internal Injuries Teeth Injury
Suspect Forced Victim : Primary Action: Suspect Force: • Lacerations Bone Injury • Other Injuries None
Phone: Cell Phone:
Person Name:
L Business
Address (Street, Apt., City, State, Zip): Pager:
Victim Type (Business): Domestic r LEOKA Activity: LEOKA Assignment:
Involvement Type (Person):
Violence
Occupation: Employer: Employer Address: Employer Phone:
Relationship to Offender: DOB: Age: Sex: Height: Weight: Build: Complexion: Eye Color:
Race: Ethnicity: I SSN: License (#, Class, State): Related Offenses): Hair Color: Hair Length: Hair Style:
NCIC#: State ID #: Facial Hair: Speech: Teeth:
Clothing Description:
Body Markings (Type, Location, Description): Solicited/Offered: Injury Type:
CONTROLLE Minor Muries Unconscious
Suspect Forced Victim: Primary Action: Suspect Force: CONFIDEN l lateral injuries Teeth injury Lacerations
NOTFOR THIRD PaZY BELEASE
THE RIALTO POLICE DEPARTMENT
REL TO: BANNER ATTORNEYS
BY: M.L. 03.20.24
INCIDENT REPORT
Agency Name: ORI#: Report Date/Time OCA#:
RIALTO POLICE DEPARTMENT 03/08/2024 13:52:5 932402219
Incident Start Date/Time: DOW: Report Type: Case Screening: CHP 180 02/28/2024 17:20:00 Wednesday INITIAL Total Loss
• Serialized Property / Hate Crime
Incident End Date/Time: Internal Incident Status:
I Evidence Collected Gang Related 50.00
02/28/2024 17:25:00
L PC 293 Sex Crime Domestic Viol.
Incident Location: Secondary Location:
1605 S RIVERSIDE AVE. RIALTO CA 92376-
Case Description: UCR Status: Cleared CITY
Reporting Area:
AXON R1540 20
Operation Method: -C. 17 OF
Penal Code: UCR Code: FM: Penal Code Description: - Counts Cong/At:
INCIDENT 00 INCIDENT
Structure TOD: Bias Motivation: Offense Location
Night NONE PARKING LOT / GARAGE
Weapon Used: Situation Code: Premise:
OTHER / NA OTHER / NA
Penal Code: UCR Code: F/M: Penal Code Description: Counts:
Comp/At:
Structure TOD: Bias Motivation: Offense Location:
Weapon Used: Situation Code: Premise:
~ Person Name: Phone: Cell Phone:
• Business N/A
Address (Street, Apt., City, State, Zip): Pager:
Involvement Type (Person): Victim Type (Business): Domestic F ] LEOKA Activity: | LEOKA Assignment:
VICTIM Violence
Occupation: Employer: Employer Address: Employer Phone:
Relationship to Offender (Person): DOB: Age: Sex: Height: Weight: Injury Type Minor Injuries Unconscious
Internal Injuries Teeth Injury
Race: Ethnicity: SSN: License (#, Class, State): Related Offenses): _Lacerations Bone Injury Other Injuries None
Suspect #1 Name: Phone: Cell Phone: Pager:
Address (Street, Apt., City, State, Zip): Occupation: Employer:
Suspect Forced Victim: Primary Action: Employer Address: Employer Phone:
Solicited/Offered: Suspect Force: DOB: Age: Sex: Height: Weight: Build: Complexion: Eye Color:
Race: Ethnicity: SSN: License (#, Class, State): Related Offense(s): Hair Color: Hair Length: Hair Style:
Clothing Description: NCIC #: State ID#: Facial Hair: Speech: Teeth:
Body Markings (Type, Location, Description): Suspect F Suspect Г Additional Additional Arrested: Suspects: Persons:
DUONG, HENRI 02616 03/08/2024 13:57:18
Reporting Officer ID# Date Reporting Officer Signature
Assisting Offiper SignatureD COPY
Assisting Officer ID# Date
CONFIDENTIAL COPY
MILLS, JAMES 00916 03/13/2024 08:23:55 Reviewing officer Signature PC 11142-11143 Reviewing Officer ID# Date NOT FOR THIRD PARTY RELEASE
THE RIALTO Pace CEOD BPARTMEN
REL TO: BANNER ATTORNEYS
BY: M.L. 03.20.24
INCIDENT REPORT - NARRATIVE
Agency Name: ORI#: Report Date/Time: OCA#:
RIALTO POLICE DEPARTMENT CA0360900 03/08/2024 13:52:54 932402219 ASSIGNMENT:
On 02/28/24, I (Officer H. Duong) was assigned to uniformed patrol for the Rialto Police Department, in the City of Rialto, County of San Bernardino. At approximately 1741 hours, I responded to a call for service to 1605 S. Riverside Ave., in reference to an agency assistance request from the Rialto Fire Department.
2021 APR 17
RFD CONTACT:
"!!
Upon arrival at approximately 1759 hours, I contacted Opt Meredith who stated he contacted the - PH injured party, later identified as Thomas Burns DOB 09/03/1958, who had minor injuries to his forehead. Cpt Meredith stated Burns tripped over a bump on the sidewalk and fell forward hitting his forehead on the sidewalk. Burns was treated for the cut on his forehead but he refused further medical care.
INJURED PARTY CONTACT:
The following is a synopsis of Burn's statements.
Burns was walking south on the north bound sidewalk of S. Riverside Ave. as he walked passed pand the sis walk. Burns er onvard ane it his forete ad ried aused elsa he ride of his. eyebrows. He complained of pain to his arm and ribs but did not want further medical aid.
EVIDENCE:
All Axon video footage and digital photographs were tagged and uploaded to Evidence.com.
DISPOSITION
This report is for documentation purposes only.
RECOMMENDATION:
Report to file.
CONTROLLED COPY
CONFIDENTIAL COPY
RESTRICTED PC 11142-11143
NOT FOR THIRP39e3AROYBRELEASE
THE RIALTO POLICE DEPARTMENT
REL TO: BANNER ATTORNEYS
BY: M.L. 03.20.24
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