CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 DEC -2 PM 3:51
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:
Minyan Vivian Payton
FULL NAME DATE OF BIRTH
-
HOME ADDRESS INCLUDING CITY, STÁTE & 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: Oct. 29,2024 TIME: _ 3:00 DAME 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. rested occurred on Riverside Are between and Cedar.
3. HOW DID DAMAGE OR INJURY OCCUR?
I was driving Southbound Riverside Ave past
the Hydrogen Generation plant where constructin was going on As I was passing the site, a rock hit my windshield. and caused a Crack
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? DYES NO which progressed.
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.
Loose rocks from the construchin site, hit my windshield. and caused my windshield to cracke
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 300.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
tem/Date: Windshield (front) Oct. 29,2024 Amount: $. 300. 00 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 300,00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: N Amount: $_
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Milan Jackson NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
N/A
ADDRESS: ADDRESS:
TELEPHONE: _ TELEPHONE:
DATE: TIME: DAM DPM 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 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" 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.
Hydrogen
Car Plant
Riverside Are CURB
PARKWAY
SIDEWALK Locust Ave
I CERTIFY IOR NECI ARE INDER DENAI TY DE PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT U
Payton 012/07/24
Self
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
RIALTO 09494
'Auto Glass & Window Tinting
rialtoautocenter.com Free Mohile Services
EAGLE SMOG. AND AUTO REPAIR
364 EAST Foothill Blvd. #1 Rialto CA 92376 909-723-0255 Sold To: /07710 27 1114). Date:
Adress: City.* Zip.
Tel: Year/Make/Model:
Qty Description Model Serial # Amount
Notes: You Must Remove Tape
Sub Total
within 2 Days
Do Not Wash Vehicle for at Tax
least 2 Days to let glue dry Total S00
Lifetime Warranty on Deposit
Windows for Water Leaks Balance
Lifetime Warranty on
Window Tint
Warranty: Free Rock Chip Repair
Customer Signature X
By Signing this Invoice you agreed to the terms