CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 DEC -9 PM 4: 20
TO PERSON OR PROPERTY RECEIVED
CITY CLERA
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:
Jose Aiden Barajas
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 First Law Group
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 314 E Rowland St., Covina, CA 91723
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 06/06/2024 1:18 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.
The incident occured at Sam V. Curtis Elementary School, 451 South Lilac Ave. Rialto, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Claimant who was at San V Curtis Eiementary Schooi, tell due the unsanitary conditions of the restroom. The fell resulted in claimant sustaining injuries to the right shin, headaches, etc.
4. WERE POLICE AT THE SCENE? • YES • NO WERE PARAMEDICS AT THE SCENE? DYES •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.
The City of Rialto and its agents, employees and others under it's control failed to maintain, train, supervise, monitor, and control hired personnel at subject school resulting in claimant's injury.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,000,000(+ EST) HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Investgation ongoing Amount: §pending
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY OF RIALTO Item/Date: 2024 DEC -9 PM Amgynt: S.
tem/Date: Amount: $
RECEIVED
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: CITY CLERK
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) Investigation ongoing NAME: Investigation ongoing
NAME:
ADDRESS: ADDRESS: _
TELEPHONE: L TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
Arrowhead Regional Medical Center NAME:
NAME:
ADDRESS: 400 N Pepper Ave, Colton, CA 92324 ADDRESS:
TELEPHONE: 909580-1000 TELEPHONE: ()
DATE: 06/06/2024 TIME DIAM MPM 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. f 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 vhen 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
SIDEWALK
CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Z Dean Hakka, Esq 12/04/2024
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
CITY OF RIALTO
1 PROOF OF SERVICE
2024 DEC - 9 PM 4: 21
2 STATE OF CALIFORNIA, COUNTY OF LOS ANGELES
RECEIVED
3 I am employed in the County of Los Angeles, State of California. I aht over thpage of 18 4 and not a party to the within action. My business address is 314 E. Rowland St., Covina, CA 91723.
5 On December 4, 2024, I served the foregoing documents) described as PLAINTIFF 'S 6 CITY OF RIALTO LIABILITY CLAIM FOR DAMAGES TO PERSON OR PROPERTY FORM on all interested parties in this action as set forth on the attached service list in the 7 following manner:
8 PLEASE SEE E-SERVICE LIST ATTACHED.
9 10 BY MAIL: I am familiar with this firm's practice of collection and processing 11 correspondence for mailing. Under that practice it would be deposited with the United States Postal Service on that same day with postage thereon fully prepaid at Los Angeles. 12 California in the ordinary course of business.
13 BY FACSIMILE: In addition to service by mail as set forth above, a copy of said documents) was also delivered by facsimile transmission to the addressee(s) pursuant to 14 Code of Civil Procedure $1013(e).
15 BY OVERNIGHT MAIL: I caused said documents) to be picked up via FEDERAL 16 EXPRESS for delivery to the addressee(s) set forth on the attached service list on the next business day.
17 18 BY ELECTRONIC SERVICE: By electronically serving the documents) to the electronic mail address set forth below on this date before 11:59:59 p.m. pursuant to anc 19 consistent with Code of Civil Procedure Section 1010.6(a)(2). (4), (5) and 1010.6(e) from email address
20 21 X STATE: I declare under penalty of perjury under the laws of the State of California 22 that the above is true and correct.
23 FEDERAL: I declare that I am employed in the office of the member of the bar of this court at whose direction the service was made.
24 Executed on December 4, 2024, at Covina, California. 25 26
7 DEAN HAKKAKI
27 Attorneys for Claimant.
28 1 SERVICE LIST
2 Rialto City Clerk's Office 150 S Palm Ave., Rialto, CA 92376 3 4
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CERTİFIED MAIL
US POSTAGE PINEY BOWES
FLS
ZIP 91723 $ 009.640
FIRST LAW GROUP
YOUP AWYERS SOR LIFE - )006148168 04 2024
314 E. Rowland St. 7021 1970 0001 7365 8618
Covina, CA 917
Rialto City Clerk's Office
VI I UF RIALTO 2024 DEC -9 PM 4: 20 RECEIVED 150 S Palm Ave., Rialto, CA 92376
9237676407 0002