CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 ОСТ - 7 PM 4:25
TO PERSON OR PROPERTY RECEIYED
CITY CLERA
1. Claims for death, injury to person, or to personal property must be filed not afer 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 5911.2). 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 9237 Address: 290 W. Rialto Ave, Rialto, CA 9237€
CLAIMANT INFORMATION:
Rafael Jr Chavez
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FULL NAME DATE OF BIRTH
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HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/A 1
наим -
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 TIME: 6:40 • AM 5 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.
Cactus Ave and Rialto Ave in the city of Rialto, CA
3. HOW DID DAMAGE OR INJURY OCCUR?
Claimant was driving on Rialto Ave when suddenly and without warning, the City of Rialto, failed to, negligently and carelessly managed, maintained, insufficiently employed, trained. supervised, entrusted, monitored, and/or operated the employees and/or- vehicle in a manner that caused the accident.
4. WERE POLICE AT THE SCENE? MYES O NO WERE PARAMEDICS AT THE SCENE? DYES MNO
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, 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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,000,000.00 + (est) HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Dr. Edgardo C Suarez D.C. Amount: $ 4.485.00
Item/Date:
Item/Date: CA Sports & Spine Center Amount: $ 1,925.00
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:
ОСТ - 7 CITY OF
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessaryt NAME: Investigation ongoing NAME:
ADDRESS: ADDRESS:
RIALTO
=.
TELEPHONE: L TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Dr. Edgardo C Suarez D.C. NAME: CA Sports & Spine Center 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; ДАМ ОРМ DATE: TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
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 vehicl icen by 8 andye point impac yo of Cy rown vehice at time of accident by A f" and location of yoursel 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.
CURB Rialto
PARKWAY
7 SIDEWALK
I CERTIFY IOR DECLAREI UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMAN OR AGENI
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
CERTIFIED MAIL
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Covina, CA 91723
Rialto City Clerk's Office
150 S. Palm Ave.,
Sz :n Hd L-100 1202 Rialto, CA 92376
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