CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 2024 MAY 29 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 §911.2) CITY CLERK RECEIVEO
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:
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:
UCTAVIO MORALES
FULL NAME -
DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP
HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING ČITY, STATE & ZIP L
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: 8-11-23 TIME: /645 • 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. 560 S. SYCAMORE AVE.
RIALTO CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
VEHICLE WAS ILLEGALLY TOWED BY OFFICER
M. LOPEZ L.D. NUMBER 02065
4. WERE POLICE AT THE SCENE? EYES NO WERE PARAMEDICS AT THE SCENE? •YES ENO
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.
MATTHEW LOPEZ 1. D. NO. 02065
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $2,971.80 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: TOWING FEES Amount: $ 2,971.80
Item/Date:
Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 2,971.80 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: ESTHER MORALES
NAME:
ADDRESS:
ADDRESS: —
TELEPHONE:
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: (
DATE: TIME:
• AM OPM DATE: TIME: DAMO 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.
INEDTIF IAn ArA. a-. INDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
OCTAVIO MORALES 5.28 - 2024
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 EMoney Enterprise EMoney EFT EMoney Gift Cards
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Transaction Approved
Reference Number: 3944
Account Number:
Cardholder: octavio r morales
Approval Code: 06401C
Invoice #: 357602
Date: 06/30/23 15:37:11
Amount: $216.80
Tax: $0.00
Total: $216.80
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CITY OF RIALTO [POS Retail] (6857) • Cherie Rodriguez • MID: Elavon Inc Copyright © 1998 - 2023. All rights reserved. Terms of 9/11/23, 3:54 PM
Invoice
Pepe's Towing Service Impound Invoice
PERES PO Box 7450, Moreno Valley CA 92552
Towing Soroice Phone: (951) 682-5682 | Fax: (951) 682-5030 Printed 9/11/2023 Released To OCTAVIO MORALES
550 S SYCAMORE AVE RIALTO CA 92376 Phone: 9095864727
Invoice # 23-0811-18312
Reason for 23109.2 - SPEED CONTEST 30 DAY HOLD
Call # 18312 Impound
Case # 932309030 VIN Number
Lien Start Date 8/14/2023 Model
2005 Mercedes-Benz C-Class (Tan)
Lien Clear Date: 9/20/2023 License Plate
Case # 932309030 Drivable Yes
Account
RIALTO PD Keys No
Date/Time Requested 8/11/2023 4:28 PM Towed from
(560 South
Date/Time Dispatched 8/11/2023 4:29 PM Sycamore Avenue) Date/Time Arrived to scene: 8/11/2023 4:40 PM Stored at Rialto Yard Date/Time Towing Time: 8/11/2023 4:53 PM 2775 N Locust, Rialto CA 92377 Date/Time Destination Arrival: 8/11/2023 5:07 PM
Date/Time Completed: 8/11/2023 5:15 PM
Date/Time Impounded: 8/11/2023 5:15 PM
Driver Vincent G.
Truck TRK 89
Date/Time Released: 9/11/2023 3:51 PM
Days Held in Impound 32 days
Notes ***30 DAY HOLD***
Storage charges Quantity
Price Line Total
(Storage - Storage Fees) Impounds/Storage: Daily Impound Rate 32 $70.00 $2,240.00 Towing charges Quantity Price Line Total
(Towing) Admin Fee 1 $95.00 $95.00
(Towing) TOWING FEE PORT TO PORT (price per hour) 1 $350.00 $350.00 (Towing) Short Lien Fee 1 $70.00 $70.00
owing Subtota $515.00
torage - Storage Fees Subtot $2,240.00
Subtotal $2,755.00
Taxes $0.00
Grand Total $2,755.00
Amount Due: $0.00 / Paid
Cash payment (Ref # CASH[TB:R]) of $2,755.00 applied on 9/11/2023 Pepe's Towing Service appreciates your business; if you have any questions regarding this invoice, please contact us at 951-682-5682. Thank you. Damage Disclaimer: I Have been advised that my vehicle may be damaged if winched, towed, unlocked, jump started, tire changed or left on unattended premises. I recognize the difficulty involved and I agree not to hold Pepe's Towing Service responsible for such damages should it result. I, the undersigned do hereby certify that I am legally authorized and entitled to take possession of the vehicle described and all personal property therein. I have received the vehicle and all personal property in satisfactory Signature: Date:
CA# 117433 USDOT: 1005094
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice https://app.towbook.com/impounds/Impound.aspx?id=15471910#Payment 1/1