CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES 2024 DEC 23 PM 5:47
TO PERSON OR PROPERTY
RECEIVEL
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). CITY CLERK
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2).
3. READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
LELLA DEBORAT ROBERTSON
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
SAME AS ABOVE
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Pio. Box 852
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): RIALTO, CA 9237Z
1. WHEN DID DANADE OR NURY OCCUR DATE: 12/21/2000-12/10/22t N/A
DAM C 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 streat names and addresses, measurements and landmarks.
3. HOW DID DAMAGE OR INJURY OCCUR?
4. WERE POLICE AT THE SCENE? DYES ENO WERE PARAMEDICS AT THE SCENE? DYES ENO
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.
rom (2) 2000 - 12/10/2024 I Was led to belem
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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. Life Set.
DAMAGES INCURRED TO DATE:
HemiDate: 12/10/24- quant damager tr Find in fusthe farter determin amone on on the Item/Date:
Amount: sLep Knion
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TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: #$300,000- ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: procited Item/Date:
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: conform And
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) advise Місция верни untie ingun
ADDRESS: 2505. Palen Ar. 214,
Cx. 92376
TELEPHONE: 909. 8202689 liaito, Ct 12336
TELEPHONE: 708 820
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
ADDRESS:
TELEPHONE: (
TELEPHONE: L)
DATE: TIME:
DAM0PM 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 comers. f a citytown 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 yoursetf 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
I CERTIFY (OR DECI ARE WINED DEala me no -- JURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT NO. ROBERTSON
LELIA
TYPE OR PRINT NAME 19/23/24
N/A DATE
RELATIONSHIP TO CLAIMANT
RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72)