CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 OCT - 7 PM 4: 25
TO PERSON OR PROPERTY
RECEIYED
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 9237(
CLAIMANT INFORMATION:
Brianna Guadalupe Cervantes
-
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TÉLEPHONE NO.
N/A
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE N/A
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 04/16/2024 6:40 DAM M/P TIME
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.
Cactus Ave and Rialto Ave in the city of Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
Claimant a passenger in a vehicle driving on Rialto Ave when suddenly and without warning, the City of Rialto, tailed to, negligently, and carelessly managed, maintained, insufficiently employed, trained, Supervised, entrusted, monitored and/or operated their employees-and/or vehicle so-as to be the sole and proximate cause of the vehicular accident giving rise to the action herein.
4. WERE POLICE AT THE SCENE? MYES•NO WERE PARAMEDICS AT THE SCENE? MYES •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.
On April 16, 2024, the City of Rialto and each of them who negligently and carelessly managed, maintained, insutticiently employes, trained, supervised. , entrusted, monitored and/or operated their employees-and/or vehicle-so as to be the sole and proximate cause of the vehicular accident- giving rise to the action herein.
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 DATE:
Item/Date: _Dr. Edgardo C Suarez D.C. Amount: $5,305.00 Item/Date: CA Sports & Spine Center Amount: $7,059.00
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: § Ongoing investigation ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Ongoing investigation Amount: $_
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information attach editional pages, if necessa 4074 OCT - 7 NAME: Investigation ongoing CITY OF
ADDRESS: ADDRESS:
PH
TELEPHONE: | ) TELEPHONE: L 1 RIALTO
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
.сл
Dr. Edgardo C Suarez D.C. NAME: CA Sports & Spine Center NAME:
ADDRESS: 236 N. Riverside Ave. ADDRESS: 399 E Highland Suite #319 Rialto, CA 92376 San Bernardino, CA 92404
TELEPHONE: 909)820-2011 TELEPHONE: (213) 465-0994
DATE: TIME: DATE: TIME:
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 • NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
Ricito Ave
CURB
PARKWAY
/ SIDEWALK
¡AVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS IOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRL
CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF CLAIMANT OR AGENT
Z Dean Hakkak, Esq 10/02/2024
TYPE OR PRINT NAME DATE
Attorney
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
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