CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 2024 AUG 12 PM12:18
RECEIVED
1. Claims for death. injury to person, or to personal properly must be filed not later than six (6) months after the occurrence (Gov. Code §911.2). CITY CLERK
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:
Erie and Karen Matkins
FULL NAME -
DATE OF BİRTH
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: OCtober ZO23 TIME:
• AM O 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. 1578 N. Gardena Ave. Roots from City trees behind house on Willow has come under Concrete and lifted and recracked, Hada
Lompany come out to remove a Piece which Is 5" Round
3. HOW DID DAMAGE OR INJURY OCCUR? Block wall 15 full oF Roots and Split.
City tree roots
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? YES 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.
over grown trees Not being treated
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO Need City to Inspect
Amount: $
Item/Date: We have Video and Root that Amount: $
uascut
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: sTBA ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 5'x 13' Concrete Patro
Amount: $
Item/Date: Remove a Replade due to
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: LIFtING Amount: S_ TBA
andcrackag s
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
NAME:
ADDRESS:
ADDRESS:
NIt
TELEPHONE: )
TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS: _
TELEPHONE:
TELEPHONE: ( )
DATE: TIME:
• AM • PM 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 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 CITY CLERK RECEIVED
/ 2014 AUG 12 PM 12:18 CITY OF RIALTO
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.
I CERTIFY IOR DECI ADELINED DEAR TY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT'OR GENT
ERIC E MATKINS 8-8-2024
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 Eric Matkins SN BERNARDINO CA 923
9. AUG 2024 PM 7 . L
CITY CLERK RECEIVEO 2024 AUG |2 PM12: 18 CITY OF RIALTO City Of Rialto Clerks Office
150 S Palm Ave
Rialto, Ca 92376
9297g-548753