CITY OF RIALTO CITY OF RIALT OTY CLERKSDATE STAMP
LIABILITY
AMII: 04
CLAIM FOR DAMAGES 2024 JUL 31
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:
Andrea Leon
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/A N/A
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
Prestige Law, 14541 Sylvan St. Van Nuys, CA 91411
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: May 01, 2024 TIME: 6:30 • AM X 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.
Sidewalk at or near 619 S Larch Ave.
3. HOW DID DAMAGE OR INJURY OCCUR?
Walking on sidewalk down Larch Ave, I tripped over the uneven concrete of the sidewalk and fell down suddenly.
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? YES XI 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.
Failure by the City of Rialto to properly maintain a safe walking surface of the sidewalk.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 500,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Still treating - approx. amount of medical bills and pain and mount: 8. 500,000 Item/Date:
Item/Date: Amount: $.
500,000
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: unknown - still treating
Amount: $_
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ unknown
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) none known
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: () TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
Loma Linda Hospital
NAME: — NAME: _
1234 Anderson St, Loma Linda, CA
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: |)
5/1/14 approx. 630
DATE: TIME: •AM XIPM DATE: TIME: • AM • 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 vehice; 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 THECLAIMANT.
RECE JUL 31 CITY OF RIALTO
CITY CLERK
RED = Uneven Concrete of
CURB Larch Ave. YED
PARKWAY
Carter St.
TIF SIDEWALK
619 Larch Ave.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
7126/24
Paul Aghabala
TYPE OR PRINT NAME DATE
Attorney for Claimant
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 *SANTA CLARITA CA 913
PITNEY BOV
29 JUL 2024 PM 1 L $9.640
PRESTICELAW
14541 Sylvan Street • Van Nuys, CA 91411
PLACE STICKER AT TOP OF ENVELOPE TO THE RIGHT
CERTÍFIED MAIL** RECEIVEr 2074 JUL 31 AMII: 04 CITY OF RIALTO Rialto City Clerk's Office
150 S. Paim Ave.
Rialto, CA 92376
7022 3330 0000 1711 1607
S2378-648799