CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES. 2024 AUG 15 PM 2: 18
TO PERSON OR PROPERTY '
RECEIVEL
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 59112). 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:
a minor, by and through his mother, Diana Ramirez
FULL NAME DATE OF BIRTH
C/O Jacoby & Meyers LLP., 10900 Wilshire Bld. 15th Floor Los Angeles, CA 90024 ( 310) 312-3300 HOME ADDRESS INCLUDING CITY, STATE & ZIP. HOME TELEPHONE NO.
N/A (310 ) 312-3300
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE _C/O Jacoby & Meyers LLP., 10900 Wilshire Blvd. 15th Floor
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
Los Angeles, CA 90024
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _3-7-2024 TIME: Approximately 2:030 AM IX 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.
Physical Education class at Rialto High School located at 595 S Eucalyptus Ave. in Rialto, CA 92376.
3. HOW DID DAMAGE OR INJURY OCCUR?
Please see "Attachment A". Investigation is pending and Claimant's treatment is ongoing.
4. WERE POLICE AT THE SCENE? • YES • NO WERE PARAMEDICS AT THE SCENE? DYES N 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.
Please see "Attachment A". Investigation is pending and Claimant's treatment is ongoing. The names of employees are uknown at this time. Investigation is pending.
6. GIVE TOTAL AMOUNT OF CLAIM include estimate of amount of any prospective injury or damage $TBD. but exceeds $35.000.0 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specifi, it doctor bills repair estimates, etc. Please attach 2 Shis iten unlimited civil cas DAMAGES INCURRED TO DATE:
Item/Date: TRA Amount: $. TRD
Item/Date: TBD Amount: $_ TRD
TBD. but exceeds $35.000.000
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ This is an unlimited civil case.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: TBD Amount: STBD
Iter/Date: TBD Amount: $_ TBD
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 5. TBD but exceeds
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessan$35,000.00 NAME: _ Unknown al this time. Investigation is pending. - NAME: Unknown at this time. Investigation is pending.
ADDRESS: Unknown at this time. Investigation is pending. ADDRESS: _ Unknown at this time. Investigation is pending- -
TELEPHONE: L _ Luvestigation is pending: TELEPHONE: L....]. Investigation is pending Claimant's treatment
8. IF INJURED, PROVIDE NAME, CONTACT INFORMHTION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED: is ongoing NAME: Loma Linda University Children's Hospital NAME: Loma Linda University School of Dentistry ADDRESS: 11234 Anderson St, Loma Linda, CA 92354 ADDRESS: 11092 Anderson St, Loma Linda. CA 92350 TELEPHONE: (909) 558 4441 TELEPHONE: (909) 338 4222
DATE: 03/07/2024_ TIME: _Unknown at CAM PM DATE: _ 03/08/2024 . TIME: Jinknown... •AM D] PM this time at this time.
9. PLEASE READ THE FOLLOWING CAREFULLY: N/A
For all vehicle accident claims, piace 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" ani 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.
N/A. Claimant
was in Physical
Education class.
2024 AUG 15 PM 2:18 CITY OF RIALTO
CURB
PARKWAY
SIDEWALK
LEERTIFY (ORDECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMAL-OR AGENT
Mariam Danielyay 8.9-2024
TYPE OR PRINT NAME DATE
Attomey
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 ORIGIN ID: SMOA (310) 312-3300 SHIP DATE: 13AUG24
CAD: 25231002NSX3600
LOS ANGELES, CA 9002 BILL SENDER
UNITED STATES U
TO RIALTO CITY CLERK S OFFICE
150 S PALM AVE
00-L0
RIALTO CA 92376
REF:
00312500
DEPT:
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2782 5650 1012
92376
WM RIVA This envelope is only for FedEx Express® shipments» CA-US SBD You can help us get vour packade safelu tn its ractination he, 06/21/24 02:33 RECEIVED 2024 AUG 15 PH 2: 18 CITY OF RIALTO
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