CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CITY
CLAIM FOR DAMAGES 2024 JUN 24 AMIO: 30
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
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: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
valerie Gonzalez
-
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 6221/24 TIME: 9:45 DAM EPM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Descrbe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
E merrill Ace and Sycamore Ave. Going north. towards
E. Rvalto Ave
3. HOW DID DAMAGE OR INJURY OCCUR?
Uneven Congrete due to road work. po light turned
green Went Slow and concret was lower causin my splash guard to come af 4, WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? LOYES CANO
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.
Road work and uneven assphet/cencret
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage = 275.06 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 275 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 6 25 24 Amount: $ 275
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: Suvene Gonzaler
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: DATE:
TIME: • AM 0 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 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. → CURB
PARKWAY
/1 SIDEWALK
JAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS OSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRI I CERTIE (OR DECLARELUNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Valerie lonzaler 4/24/24
-
TYPE OR PRINT NAME
Self
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 28 FERNANDEZ 993 W Valley Blvd. Suite 315
Bloomington, CA 92316
(909) 272-7276
[email protected] DATE
BODY FENDER
06-24-24
CUSTOMER PHONE NO
Valerie Gonzalez
MAKE MODEL YEAR VIN NUMBER
Honda Accord Sport 2018
LABOR AMOUNT
Remove : Install Engine Splash Guard 75"*
QTY PART NO DESCRIPTION AMOUNT
1 Engine Splash Guard 200°
ED
024 JUN 24 AMID: 30 CLERK
SUB TOTAL 275°
TAX
TOTAL 275%
DEPOSIT -
BALANCE DUE
2750
I HEREBY AUTHORIZE FERNANDEZ BODY FENDER THE ABOVE LISTED REPAIRS AND NECESSARY MATERIALS. YOU AND YOUR EMPLOYEES MAY OPERATE ABOVE VEHICLE FOR PURPOSE OF TESTING INSPECTION, OR DELIVERY AT MY RISK. IT IS ALSO UNDERSTOOD THAT YOU WILL NOT BE HELD RESPONSIBLE FOR LOSS OR DAMAGE TO VEHICLE OR ARTICLES LEFT IN THE VEHICLE IN CASE OF FIRE, THEFT, OR ANY OTHER CAUSE BEYOND YOUR CONTROL. VISIBLE DAMAGES, IF CUSTOMER SIGNATURE: