CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2025 JAN -6 PM 4: 14
CLAIM FOR DAMAGES
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:
Maida Barrios
DATE OF BiRTH Hard of Hear
FULL NAME
(onty text
HOME ADDRESS INCLUDING CITY, STATE & ZIP OME TELEPHONE N Husban
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): SAME
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: Aug 22. 2024 7:20 DAM D PM 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.
Foothill Blvd
3. HOW DID DAMAGE OR INJURY OCCUR? Hit
Police come my Lar
4. WERE POLICE AT THE SCENE? * YES ONO WERE PARAMEDICS AT THE SCENE? YES DO 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.
Rialto Police
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:
Amount: $_ 18, 084.96
Item/Date: _ sel tach
Item/Date: Amount: $
2 Hospital Bill's ages
missWoRk 2 JOBS
1Amulanee Little pain of suffaring
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Nemate: see attach sheets 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: Video trim Bank America NAME:
ADDRESS: Foothiil in Rialta ADDRESS:
TELEPHONE: ( TELEPHONE: ()
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
MAME Arrowhead Regional Medical Center mAME Arrowhead Regional Medical Center ADDRESS: 400 N. Pepper Ave ADDRESS: 400 N. Pepper Ave
Colton, CA. 92324 Colton, CA 92324
TELEPHONE: 909580-1000 TELEPHONE: (409 580- 1000
DATE: Aug 22,2024 TME: 1:45 AM PM DATE: AUG 27, 2024ME: 12:00 DAMIeN
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 Citv/Town vehicle: location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicie 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. see page 2 • of Police Report
CURB
PARKWAY
7 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 TRI I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Maida Barrios 11•12•2024
TYPE OR PRINT NAME DATE
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 Doctor bill $ 103.85 see 1
Doctor bill $204.61 see 2
Ambulance bill $1.655.45 see 3
Doctor bill $ 6,321.83 see H
Doctor bill $ 340.17 see S
Arrowhead Hospital bill $ 1,470,97 seel
Arrowhead Hospital bill $ 3,943.58 See O
Missed Work Rainbow Store PTO $ 208.00 see 8
Missed Work Rainbow Store PTO $ 224.00 see @
Duarte High School Work Missed 4 days # 612.50 see lo
Pain and Suffering $ 3,000 couldn't stand pain
for 2 weeks.
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
•TRAFFIC COLLISION REPORT
CHP 555 Page 1 (Rev. 4-11) OPI 060 2 Page 1 of 4
SPECIAL CONDITIONS NUMBER HIT & RUN • CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER
INJURED FELONY
1 SAN BERNARDINO 2024-00099849
NUMBER KILLED HIT & RUN COUNTY REFORTING DISTRICT SEAT DAY OF WEEK TOW AWAY
MISDEMEANOR
On-Duty Emergency Vehicle SAN BERNARDINO S MT WOF SOYES XINO COLLISION OCCURRED ON MO. DAY YEAR TIME (2400) NCIC # OFFICER I.D.
E FOOTHILL BLVD 08/22/2024 0739 3610 50772
MILEPOST INFORMATION GPS COORDINATES PHOTOGRAPHS BY: •NONE FEET/MILES OF LATITUDE 34.1067587958568NGITUDE - -117.361628079017
LAT INTERSECTION WITH STATE HWY REL RIALTO PD
[X]OR: 520 FEETMEG W OF NORTH ACACIA AVENUE ]YES [X) No PARTY DRIVERS LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEUCOLOR EXPLORER LICENSE NUMBER STATE FORD
01 B6514149 CA M H 2020 BLACK 1600717 CA
DRIVER NAME (FIRST, MIDDLE, LAST)
ERICA JEAN DUQUE OWNER'S NAME SAME AS DRIVER
PEDES- STREET ADDRESS CITY OF RIALTO
TRIAN
128 N WILLOW AVE OWNER'S ADDRESS [X) SAME AS DRIVER
PARKED CITY/STATE/ZIP 128 N WILLOW AVE RIALTO CA 92376
VEHICLE
• RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF: [X OFFICER DRIVER •OTHER BICY- TsEx HAIR EYES [HEIGHT WEIGHT BIRTHDATE Year RACE RETAINED BY DRIVER LIST
F BRO BRO 5 1 145 07/20/1979 W PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: 1FM5K8AB5LGC99765 (909)820-2550 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER LUNK. NONE IX MINOR
SELF INSURED 48 MOD. MAJOR ROLL-OVER
IRO ON STREET OR HIGHWAY TSPEED LIMIT
CA DOT
RAVEI
EE FOOTHILL BLVD 25 CAL-T TCPIPSC MC/MX
STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODELCOLOR CAMRY LICENSE NUMBER STATE
PARTY DRIVER'S LICENSE NUMBER TOYOTA
02 B7535800 CA M G 2022 WHITE CA
DRIVER NAME (FIRST, MIDDLE, LAST)
MAIDA BARRIOS OWNER'S NAME X SAME AS DRIVER
THAN STREET ADDRESS
OWNER'S ADDRESS X SAME AS DRIVER
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF: [X OFFICER DRIVER •OTHER HAIR EYES HEIGHT WEIGHT Ma. BIRTHDATE Year RACE RETAINED BY DRIVER BLK BRO 5-1 135 H PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER LUNK. NONE X MINOR *
MERCURY INSURANCE GROUP 01 •MOD. •MAJOR •ROLL-OVER X IX
ON STREET OR HIGHWAY SPEED LIMIT CA DOT
W EAST FOOTHILL BLVD 25 CAL-T TCP/PSC мс/MX
PARTY DRIVER'S LICENSE NUMBER STATE [CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE DRIVER NAME (FIRST, MiDDLE, LAST)
• OWNER'S NAME SAME AS DRIVER
PEDES STREET ADDRESS
TRIAN
OWNER'S ADDRESS •SAME AS DRIVER
PRICE CITATE/ZIP
DISPOSITION OF VEHICLE ON ORDERS. OF: OFFICER DORIVER MOTHER
BICY- SEX THAIR EYES HEIGHT WEIGHT TRACE
eLIST Mo.
- PRIOR MECHANICAL DEFECTS: • NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER. POLICY NUMBER •UNK. NONE MINOR
•MOD. MAJOR ROLL-OVER
TON STREET OR HIGHWAY SPEED LIMIT CA-
PHANEL DOT
CAL-T TCP/PSC MC/M
PREPARER'S NAME DISPATCH NOTIFIEO REVIEWER'S NAME DATE REVIEWED Mata 50772 [X] YES _ONO ONA Siems, Michael 09/26/2024
An Internationally Accredited Agency 2015 CHP 555 2024-0006984659881 POF 4 "STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
'TRAFFIC COLLISION CODING
CHP 555 Page 2 (Rev. 4-11) OPI 060 S Page 2 of 4
DATE OF COLLISION (MO. DAY YEAR) TIME (2400) NCIC # OFFICER I,D. NUMBER 08/22/2024 0739 3610 50772 2024-00099849
OWNER'S NAME OWNER'S ADDRESS NOTIFIED
CITY OF RIALTO 128 N WILLOW AVE RIALTO CA 92376 [X]YES
PROPERTY
DAMAGE DESCRIPTION OF DAMAGE
SCRATCHES TO PUSH BAR
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES
OCCUPANTS CHILD RESTRAINT A - CELLPHONE HANDHELD
A - NONE IN VEHICLE Q - IN VEHICLE USED B - CELLPHONE HANDSFREE
B- UNKNOWN C - ELEGTRONIC EQUIPMENT
G - LAP BELT USED: ) - RADIO / C
D - LAP BELT NOT USED T - IN VEHICLE IMPROPER USE :. SMOKING 1 - DRIVER E - SHOULDER HARNESS USED J.- NONE IN VEHICLE 123 2 TO6 - PASSENGERS. EJECTED FROM VEHICLE
F: SHOULDER HARNESS NOT USED
456 7 - STATION WAGON REAR G - LAPISHOULDER HARNESS USED M/ C BICYCLE HELMET - NOT EJECTE! 8 - REAR OCC, TRK. OR VAN H- LAP/SHOULDER HARNESS NOT USED DRIVER PASSENGER - FULLY EJECTE g: POSITION UNKNOWN J- PASSIVE RESTRAINT USED V - NO X - NO 3 - PAKNOWY EJECTED J- READIN 7 0 - OTHER K-PASSIVE RESTRAINT NOT USED •W- YES Y-YES K- OTHEI
P - NOT REQUIRED
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE. 01/02 SPECIAL INFORMATION 01 02 MOVEMENT PRECEDINC
TRAFFIC CONTROL DEVICES COLLISION
LIST NUMBER #) OF PARTY. AT FAULT
02 A VE SECTION VIOLATED. A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED
B CELL PHONE HANDHELD IN USE X B PROCEEDING STRAIGHT
C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE RAN OFF ROAD
X D NO CONTROLS PRESENT / FACTOR' X X D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER* E SCHOOL BUS RELATED E MAKING LEFT TURN F 75 FT MOTORTRUCK COMBO® F MAKING U TURN
G 32 FT TRAILER COMBO G BACKING
H H SLOWING / STOPPING
WEATHER (MARK 1 TO 2 ITEMS) X D BROADSIDE I PASSING OTHER VEHICLE
X A CLEAR E HIT OBJECT J CHANGING LANES
B CLOUDY F OVERTURNED K PARKING MANEUVER
C RAINING G VEHICLE / PEDESTRIAN L ENTERING TRAFFIC
D SNOWING H OTHER*: M OTHER UNSAFE TURNING
E FOG/VISIBILITY FT. N N XING İNTO OPPOSING LANE
F OTHERE: MOTOR VEHICLE INVOLVED WITH O PARKED
G WIND A NON - COLLISION P MERGING
LIGHTING Q TRAVELING WRONG WAY
X A DAYLIGHT X C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTOR(S) R OTHER*:
01 02
B DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS) C DARK - STREET LIGHTS E PARKED MOTOR VEHICLE A VC SECTION VIOLATION BEEs D DARK - NO STREET LIGHTS F. TRAIN •NO
E DARK - STREET LIGHTS NOT G BICYCLE B VOSECTION VIOLATION: BYES FUNCTIONING* H ANIMAL: [NO SOBRIETY - DRUG
ROADWAY SURFACE C VOSECTION VIOLATION: BEES 01 02 PHYSICAL X A DRY | FIXED OBJECT: (MARK 1 TỌ 2 ITEMS)
B WET A HAD NOT BEEN DRINKING
C. SNOWY - ICY J OTHER OBJECT; E VISION OBSCUREMENT: B HBD-UNDER THE INFLUENCE D SLIPPERY (MUDDY, OILY, ETC.) X F INATTENTION*: C HBD - NOT UNDER INFLUENCE* ROADWAY CONDITIONS G STOP & GO TRAFFIC D HBD - IMPAIRMENT UNKNOWN* (MARK 1 TO 2 ITEMS) PEDESTRIAN'S ACTIONS H ENTERING / LEAVING RAMP E UNDER DRUG INFLUENCE" A HOLES, DEEP RUT X A NO PEDESTRIANS INVOLVED: 1 PREVIOUS COLLISION F IMPAIRMENT - PHYSICAL* B LOOSE MATERIAL ON ROADWAY* CROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN X C OBSTRUCTION ON ROADWAY" ' INTERSECTIO & DEFECTIVE VEH. EQUIP. CRED H NOT APPLICABLE D CONSTRUCTION - REPAIR ZONE C CROSSING IN CROSSWALK - NOT. I SLEEPY / FATIGUED'
TE REDUCED ROADWAY WIDTH AT INTERSECTION
F FLOODED" D CRÖSSING - NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER" E IN ROAD - INCLUDES SHOULDER MOTHER:
H NO UNUSUAL CONDITIONS. F NOT IN ROAD N NONE APPARENT
G APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHICLE
SKETCH MISCELLANEOUS
The area of impact is approximately 520 feet
west of the west curb line prolongation of
North Acacia Avenue and 21 feet north of the
south curb line of East Foothill Blvd.
NORTHACACH AVE
ZANK OF AGRICA HIVATE DRAVEWAY
An Internationally Accredited Agency 2015 CHP 555 2024-00099359 Pace 3QF 4
STATE OF CALIFORNIA
INJURED / WITNESS / PASSENGERS Page 3 of 4
CHP 555 Page 3 (Rev. 11-06) OPI 065
TIME (2400) NCIC # OFFICER 1D. NUMBER
DATE OF COLLISION (MO. DAY YEAR)
08/22/2024 0739 3610 50772 2024-00099849
EXTENT OF INJURY ("X" ONE) INJURED WAS (X"ONE)
PARTY 'SAFET
WITNESS PASSENGER SEX NUMBER PosT EJECTED
AGE OTHER VISIBLE COMPLAINT
ONLY ONLY, FATAL SEVERE DRIVER PASS. PED. BICYCLIST OTHER
INJURY INJURY INJURY OF PAIN
7# 47 F 02 1
NAME / D. O. B. / ADDRESS MAIDA BARRIOS 07/17/1977 TELEPHONE (562)417-3159
(INJURED ONLY) TRANSPORTED BY: TAKEN TO:
AMR ARMO
DESCRIBE INJURIES
COMPLAIN OF PAIN TO NECK AND BACK
VICTIM OF VIOLENT CRIME NOTIFIED
L
TELEPHONE
NAME / D. O. B. / ADDRESS
TAKEN TO:
INJURED ONLY) TRANSPORTED BY:
DESCRIBE INJURIES
I VICTIM OF VIOLENT CRIME NOTIFIED
1#
TELEPHONE
NAME / D. O. B. / ADDRESS
(INJURED ONLY) TRANSPORTED BY: TAKEN TO
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
7#
TELEPHONE
NAME / D. O. B. I ADDRESS
(INJURED ONLY) TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
•* 0
TELEPHONE
NAME / D. O. B. I ADDRESS
(INJURED ONLY) TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
•* L
NAME / D. O. B. / ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES
•VICTIM OF VIOLENT CRIME NOTIFIED
TLD. NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR
PREPARER'S NAME
Mata 50772 08/22/2024 Siems, Michael 09/26/2024
555 b06.fr
015 CHP 555 2024-00099849 Page 3 OF.
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL
CHP 556 (Rev 7-90) OPI 042 Page 4 of 4
DATE OF INCIDENT/OCCURRENCE TIME (2400) INCIC NUMBER OFFICER L.D. NUMBER NUMBER 08/22/2024 0739 3610 50772 2024-00099849
"X' ONE "X ONE TYPE SUPPLEMENTAL (X APPLICABLE)
[X) Narrative [Xl Collision report •BA update •Fatal • Hit and run update • Supplemental •Other: • Hazardous miterials School bus Lother:
CITY/COUNTY/JUDICIAL DISTRICT SAN BERNARDINO SAN BERNARDINO REPORTING DISTRICT/BEAT CITATION NUMBER
LOCATION/SUBJECT STATE HIGHWAY RELATED
E FOOTHILL BLVD / NORTH ACACIA AVENUE • Yes [X) No
See attached document.
PREPARER'S NAME AND ID. NUMBER (DATE [REVIEWER'S NAME DATE Mata 50772 t202122 Siems, Michael 09/26/2024
Use previous editions until depleted. 8 OSP 98 16969
2015 CHP 555 2024-00099849 Page 4 OF 4
•
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 1
DATE OF INCIDENT TIME NIC NUMBER OFFICER I.D. REPORT NUMBER 08/22/2024 0739 3610 50772 2024-99849
1 NOTIFICATION:
2 3 On 8/22/2024 at about 0752 hours, I was notified of a traffic collision involving a Rialto Police Department on-duty police 4 officer. Rialto PD requested assistance with the collision investigation. The collision occurred at about 0739 hours, west 5 of the interaction of East Foothill Blvd. and North Acacia Avenue, in the City of Rialto. 6 7 All speeds, times and measurements are approximate. All measurements were obtained by satellite mapping. 8 9 PARTIES:
10 11 Driver #1 (Duque, Erica) is an active on-duty police officer for the City of Rialto. I spoke to Duque, while at the collision 12 scene. She was uninjured during the collision and did not complain of any pain. She provided a statement reference the 13 collision.
14 15 Driver #2 (Barrios, Maida) was identified by her valid, California Driver's License. I spoke to Barrios at Arrowhead 16 Regional Medical Center Emergency Waiting Room, located at 400 North Pepper Avenue, Rialto, CA. At the time of 17 my contact, Barrio's complained of pain to her back and neck. She initially denied medical aid, when offered immediately 18 after the collision. She later requested an ambulance for a transport to the hospital. 19 20 VEHICLES:
21 22 Vehicle #1 - 2020 Ford Explorer. Black/White. CA-1600717 (Exempt) 23 City of Rialto, On-Duty Police Vehicle Unit, Unit #1613 24 Vehicle #1 was moved out of the roadway, prior to my arrival. I located the vehicle in a nearby parking lot. There was a 25 minor scratch on the vehicle's push bar as a result of the collision. 26 27 Vehicle #2 - 2022 Toyota. Camry, CA -
28 Vehicle #1 was moved out of the roadway, prior to my arrival. I located the vehicle in a nearby parking lot, parked within 29 a parking stall. There was collision damage to the driver side rear fender and rear bumper as a result of the collision. 30 31 STATEMENTS:
32 33 Driver #1 was on-duty at the time of the collision. Duque stated she was driving eastbound in the #2 lane of East Foothill 34 Blvd, west of the intersection of North Acacia Avenue. She came to a stop because several vehicles were backed up, due 35 to the ongoing roadway construction. She looked away from the roadway to check her air conditioning settings then 36 slowly proceeded straight. Duque recalled a large glare from the sunlight facing her as she proceeded to go east. As she 37 proceeded straight, a white vehicle came into view and Duque immediately pressed on the brakes to come to a stop. Duque 38 felt an impact to the front of her vehicle, where the front of V1 collided with the rear driver side of V2. Duque contacted PREPARER'S NAME I.D. NUMBER DATE REVIEWER'S NAME DATE:
A. Mata 50772 09/04/2024
CHP 556
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 2
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. REPORT NUMBER 08/22/2024 0739 3610 50772 2024-99849
1 Driver #2 and asked if she needed medical aid. Driver #2 denied medical aid and both vehicles were later moved to a 2 nearby parking lot.
3 4 Driver #2 was facing northbound and stopped to enter the roadway from a private business parking lot. She waited for 5 several vehicle to pass, due to ongoing construction. Barrios stated she observed the police vehicle stopped (after vehicle 6 proceeded straight). Barrios believed Vehicle #1 gave her a pass to continue into the road. She then proceeded straight 7 and was going to turn left to go west on East Foothill Blvd. As she progressed through the eastbound lanes, she felt an 8 impact to the rear of her vehicle. Barrios stated she believed the officer was on her cell phone. I asked Barrios if she saw 9 a cell phone in the officer's hand, and she stated no. Barios confirmed she observed the officer looking down prior to 10 entering the roadway. Driver: #2 requested medical aid for a complaint of pain and transported to ARMC. Vehicle #2 11 was moved to a nearby parking lot.
12 13 VIDEO SURVEILLANCE:
14 15 I made contact with Rialto Tire Shop, located at 409 East Foothill Bivd. I spoke with Manager Javier Ledesma reference 16 any video surveillance from exterior cameras that may have captured the collision. Ledesma searched and located footage 17 of the collision. A copy of the video was emailed to me. I then made a copy of the video and tagged it into the SBPD 18 Evidence Locker (Tag #2024-9211).
19 20 I reviewed the video surveillance. The time stamp is behind one hour, from real time. At 06:20:55, Vehicle #2 is seen 21 waiting to exit the private parking lot, with the left turn signal activated. Several eastbound vehicles slow down and come 22 to a stop in the #1 eastbound lane. At 06:21:13, Vehicle #1 comes into view and comes to a stop in the #1 eastbound lane, 23 approximately 100 feet west of the driveway, where Vehicle #2 is located. As traffic begins to move eastbound, Vehicle 24 #1 stays stopped for about 5 seconds, then slowly proceeds eastbound. At the same time, Vehicle #2 waits for vehicles to 25 clear and proceeds to enter the roadway to make a left turn. Vehicle #2 is within the #2 lane of the roadway, when Vehicle 26 #1 continues eastbound and does not yield to Vehicle #2, resulting in the front of Vehicle #1 colliding with the rear driver 27 side of Vehicle #2.
28 29 PHOTOGRAPHS:
30 31 Photographs of the vehicles, driver's and collision scene were taken by Rialto PD, prior to moving the vehicles out of the 32 roadway. The photographs were emailed to me. I then made a copy of the photographs and tagged them into the SBPD 33 Evidence Locker (Tag #2024-9211)
34 35
PREPARER'S NAME I.D. NUMBER DATE REVIEWER'S NAME DATE
A. Mata 50772 09/04/2024
CHP 556
..
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL • PAGE 3
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. REPORT NUMBER 08/22/2024 0739 3610 50772 2024-99849
1 SUMMARY:
2 3 Driver #1 was on-duty and driving a marked police vehicle. She was traveling eastbound in the #2 lane of East Foothill 4 Blvd. She stopped, due to slowed traffic from roadway construction. Driver #1 looked away from the roadway and 5 proceeded straight. At the same time, Driver #2 observed the police vehicle stopped, allowing several feet of space to the 6 front of the police vehicle. Driver #2 entered the roadway to make a left tum, while Driver #1 was faced with a large glare 7 from the sunlight. The front of Vehicle #1 collided with the rear driver side of Vehicle #2. 8 AREA OF IMPACT:
10 11 The area of impact was determined by Rialto PD officers at the scene. The area of impact where the front of VI collided 12 with the rear driver side of V2 is approximately 520 feet west of the west curb line prolongation of North Acacia Avenue 13 and 21 feet north of the south curb line of East Foothill Blvd. 14 CAUSE:
15 16 The cause of this collision was determined through the statements of the involved parties, and video evidence 17 located. The investigation therefore determined that Driver #1 (Duque) was the cause of this collision by violating 18 the following section of the California Vehicle Code 21804(b) - Right-of-Way, which states:
19 20 A driver having yielded to traffic may proceed to enter or cross the highway, and the drivers of'all other vehicles 21 approaching on the highway shall yield the right-of-way to the vehicle entering or crossing the intersection. 22 23 RECOMMENDATION:
24 25 None.
PREPARER'S NAME I.D. NUMBER DATE REVIEWER'S NAME DATE
A. Mata 50772 09/04/2024
CHP 556
→ CalPERS 024452
.. BOX 70000 EXPLANATION OF BENEFITS
JAN NUYS, CA 91470-0001
ISSUE DATE PAGE E038586
September 14, 2024 00001 OF 00003
Subscriber's Name: MAIDA BARRIOS
Identification Number:
roup Number DB2501
roup Name CALPERS PERS GOLD
ACTIVES(PA) REGIONS
Product: Medical Plan
32 MAIDA BARRIOS
Srovider of Services: 1306899166 202400274
Patient's Name: MAIDA BARRIOS Provider CALIFORNIA EMERGENCY PHYS Claim Number: Place of Service: Outpatient
Člaim Processed Date: 09/11/24 Patient Acct. Number: E8000121450901 Paid Amount: $179.10 To: CALIFORNIA EMERGENCY PHYS
It is your responsibility to pay: $340.17 It is not your responsibility to pay: $704.73 Thank you for using a Network Participating Provider.
COINSURANCE 20240917801 J
SERVICE TYPE OF SERVICE TOTAL OTHER PATIENT APPLIED TO COPAYMENT CLAIMS DATE(s) BILLED MOUNTS: SAVINGS DEDUCTIBLE AMOUNT PAYMENT .08/22/24 Emergency Service 1,224.00 704. 73/01 295.39/02 44.78/03 179.10 TOTAL THIS CLAIM 1,224.00 0.00 704,73 295.39 44.78 179.10 CAEAP518 COMS Sequence Number: 1306899166 202400274
Patient's Name: MAIDA BARRIOS Provider of Services: CALIFORNIA EMERGENCY PHYS Claim Number: Patient Acety Number: Cut00t21586001 Outpatient Claim Processed Date: 09/11/24
Paid Amount: $415.42 To: CALIFORNIA EMERGENCY PHYS
It is your responsibility to pay: $103.85 It is not your responsibility to pay: $704.73 Thank you for using a Network Participating Provider.
COINSURANCE
SERVICE TYPE OF SERVICE TOTAL OTHER PATIENT APPLIED TO COPAYMENT CLAIMS DATE(s) BILLED AMOUNTS) SAVINGS DEDUCTIBLE AMOUNT PAYMENT 08/27/24 Emergency Service 1,224,00 704.73/01 103.85/03 415.42 TOTAL THIS CLAIM 1,224.00 0.00 704.73 0.00 103.85 415.42 Member's Medical Deductible Applied to Date: $500.00
THIS IS NOT IL
Anton a Cal i ad at reace Anem Bies, minate series only an of an a le rene til and Heater osan in any him.. liable for benefits payable. Independent licensees of the Blue Cross Association.
EXPLANATION OF BENEFITS
ISSUE DATE PAGE E038586
September 14, 2024 00002 OF 00003
Subscriber's Name: MAIDA BARRIOS
Identification Number:
Group Number: DB2501
Group Name: CALPERS PERS GOLD
ACTIVES(PA) REGIONS
Product: Medical Plan
DETAIL MESSAGE:
01 02
03 HAVE QUESTIONS??
Order The kards "check chains statust Revoevenefits ,
OR call our dustoMeR SERVICE DEPARTMENt+-877-737-9776
MAIL ALL INQUIRIES COS ANGELES SOS 0050-AND HEALTH INSURANCE CO
OR CLAIMS
WE SUGGEST THAT YOU RETAIN THIS COPY FOR YOUR INCOME TAX RECORDS.
THIGHS NOT A BILI
WGW2EB 06/06
CalPERS 024871
P.O. BOX 70000. EXPLANATION OF BENEFITS
VAN NUYS, CA 91470-0001
ISSUE DATE PAGE E038669
September 7, 2024 00001 OF 00003
2 Santricate on Mumber: MAIDA BARRIOS
DB250I
Group Number: CALPERS PERS GOLD
ACTIVES( PA) REGIONS
*******************ALL FOR AADC 923 Product: Medical Plan 9841 1 AB 0.593
MAIDA BARRIOS
Sequence Number: 202400028
Patient's Name: MAIDA BARRIOS rovider of Services
Claim Patient set Cumber: 0561810624 Service: Outpatient Claim Processed Date: 09/04/24
Paid Amount: $0.00
It is your responsibility to pay: $204.61 It is not your responsibility to pay: $582.39 Thank you for using a Network Participating Provider.
• COINSURANCE
SERVICE TYPE OF SERVICE TOTAL OTHER PATIENT APPLIED TO COPAYMENT CLAIMS DATE(s) BILLED AMOUNTS) SAVINGS DEDUCTIBLE AMOUNT PAYMENT 08/22/24 Radiology-Extremity 50,00 31.82/01 18.18/02 0.00 08/22/24 CT Scan-Head/Neck 124.00 88. 48/01 35.52/02 0,00 08/22/24 CT Scan-Head/Neck 124.00 88.48/01 35.52/02 0.00 08/22/24 Radiology-Spine 31.00 19.20/01 11,80/02 0.00
08/22/24 Radiology-Spine 31.00. 19.20/01 11.80/02 0.00
08/22/24 CT Scan-Spine 168.00 116.92/01 51,08/02 0.00
08/22/24 CT Scan-Spine 168.00 168.00/03 0.00
08/27/24 Radiology-Extremity 30.00 15.65/01 14.35/02 0.00 08/27/24 Radiology-Extremity 30.00 15. 65/01 14.35/02 0.00 NOT
them Blue Cross Life and Health Insurance Company provides administrative services only and does not assume any financial risk or obligation with respect to clain ue Cross of California, using the trade name Anthem Blue Cross, administers claims on behalf of Anthem Blue Cross Life and Health insurance Company and is no liable for benefits payable. Independent licensees of the Blue Cross Association.
EXPLANATION OF BENEFITS
ISSUE DATE PAGE E038669
September 7, 2024 00002 OF 00003
Subscriber's Name: MAIDA BARRIOS
Identification Number:
roup Number: DB250I
roup Name: CALPERS PERS GOLD
ACTIVES(PA) REGIONS
Product: Medical Plan
COINSURANCE
SERVICE TYPE OF SERVICE TOTAL OTHER PATIENT APPLIED TO COPAYMENT CLAIMS DATE(s) BILLED AMOUNT(S) SAVINGS DEDUCTIBLE AMOUNT PAYMENT 08/27/24 Radiology-Spine 31.00 18,99/01 12.01/02 0.00
TOTAL THIS CLAIM 787.00 0.00 582.39 204.61 0.00 0.00
Member's Medical Deductible Applied to Date: $204.61
DETAIL MESSAGE:
01 - Ters "the members therefore, is hot responsible vod amis amount, participating provi- 02 amount to your Your deductible is the amount you pay for 03 - The doctor/facility billed for this care more health care before we start sraring the coste times than our guidelines allow.
Therefore, the member's plan doesn't pay
networkount if they chose to receive care from a doctor/facility obt in their bian's HAVE QUESTIONS??
ROS ANGEL 8S: CAS 00E0-AHO HEALTH INSURANCE CO
WE SUGGEST THAT YOU RETAIN THIS COPY FOR YOUR INCOME TAX RECORDS. 'INIS IS NOT'A BILI
WGW2EB 06/06
11/13/24, 4:19 PM Customer Invoice
CITY OF RIALTO AMBULANCE SERVICE Customer Invoice
PO BOX 269110 Printed on 11/13/2024
SACRAMENTO, CA 95826-9110
(800) 906-6552
Customer Information Service Information
BARRIOS, MAIDA Date/Time of Service: 08/22/2024 / 07:29:06 Run Number: 24-659270
Incident Number: 24-209297
Location: 409 E FOOTHILL BLVD
Facility: ARROWHEAD REGIONAL MEDICAL
CENTER
Address: 400 N PEPPER AVENUE
Primary Payor: MERCURY AUTO INSURANCE/10730
Charge Description Quantity Unit Price Amount
Advanced Ambulance Service 1.00 $1,579.25 $1,579.25
Mileage 3.00 $25.40 $76.20
Total Charges: $1,655.45
Check # Transaction Amount
Credit Description Payor Date
No Credits Processed
Total Credits: $0.00
PLEASE PAY THIS AMOUNT: $1,655.45
DETACH ALONG THE ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT. THANK YOU.
Patient Name: BARRIOS, MAIDA
Run Number: 24-659270
Incident Number: 24-209297
Today's Date: 11/13/2024 Amount Enclosed:
$
Remit Payment To: CITY OF RIALTO AMBULANCE SERVICE
PO BOX 269110
SACRAMENTO, CA 95826-9110
https://portal.webillems.com/Main/Displaylnvoice.aspx 1/1 CalPERS 026348
P.O. BOX 70000 EXPLANATION OF BENEFITS
VAN NUYS, CA 91470-0001
ISSUE DATE PAGE E043502
September 30, 2024 00001 OF 00003
Sant ricate Manumber: MAIDA BARRIOS
Group Number: DB2501
Group Name: CALPERS PERS GOLD
ACTIVES (PA) REGIONS
*******************ALL FOR AADC 923 Product: Medical Plan 1876 1 AB 0.593
MAIDA BARRIOS
1558410217 202400064
ARROWHEAD REGIONAL MEDICA
24257CM8500 lace of Service Outpatient
Claim Processed Date: 09/27/20 atient Acct. Number: H10014560260 Paid Amount: $2,326.38 To: ARROWHEAD REGIONAL MEDICA
It is your responsibility to pay: $6,321.83
COINSURANCE
SERVICE TYPE OF SERVICE TOTAL OTHER PATIENT APPLIED TO COPAYMENT CLAIMS DATE(s) BILLED AMOUNT(S) SAVINGS DEDUCTIBLE AMOUNT PAYMENT 08/22/24 MEDICAL SERVICES 8,648.21 5,673.22/03 598. 61/01 2,326.38
50.00/02
TOTAL THIS CLAIM 8,648.21 5,673.22 0.00 0.00 648.61 2,326.38* Member's Medical Deductible Applied to Date: $500.00
DETAIL MESSAGE:
02 = This is your share of the most coinsuran didn't pay it at the time you got care, the copay. If you hospital may bill you for it.
03 - We based on the allows for this carbill for the
doctor/facility charged more than
difference between the two amounts.
If you need care for
an urgent care center instead of emergency room. Use our mobile app or loa our website to find an urgent care in your plan's network. * All services included in this claim fall under the No Surprises Act. The member is only responsible for their copay, percentage of the cost (coinsurance), and deductible. The doctor/facility can't bill the member for more.
THIS IS NOT A BILL
Anthem Blue Cross Life and Health Insurance Company provides administrative services only and does not assume any financial risk or obligation with respect to claims Blue Cross of California, using the trade name Anthem Blue Cross, administers claims on behalf of Anthem Blue Cross Life and Health insurance Company and is not liable for benefits payable. Independent licensees of the Blue Cross Association.
EXPLANATION OF BENEFITS
ISSUE DATE E043502
September 30, 2024 00002 OF 00003
Subscriber's Name: MAIDA BARRIOS
Identification Number:
group Number DB2501
roup Nane CALPERS PERS GOLD
ACTIVES (PA) REGIONS
Product: Medical Plan
HAVE QUESTIONS??
order 1Checkards a check ctains statust Review benefitss benefits, verify family moR call over duSTOMER SERVICE DEPARTMENTartAcªt•87 1-897-737-1776
MAIL ALL INQUIRIES ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE CO OR CLAIMS "
LOS ANGELES, CA 20060-0007
WE SUGGEST THAT YOU RETAIN THIS COPY FOR YOUR INCOME TAX RECORDS.
THIS IS NOT A BIN.
WGW2EB 06/06
STAVEME
MULTIP MAYS PAY
vituity 02222
SCAN FOR MOBILE www.ePayitOnline.com
PAYMENT Online Code ID: VITUBIL2 Access#: 16100790-1-1735 Account Information or to enter your
insurance information
CEP AMERICA CALIFORNIA
Tax Id: Phone (866) 954-4405, International # (209) 252-0601 Location of Service: ARROWHEAD REGIONAL MED CTR
Use the detachable Payment Stub below and
Rendering Provider: NEWTON, ERNEST, P.A. Mail enclosed return envelope Statement Date: 11/04/24
Pay with a picture in seconds! AppStore
Account #: рач
Search Papaya Payments in the App Store
Patient Amount Due: $340.17 or go to www.ppaya.com/pay Google Play Primary Insurance: ANTHEM BLUE CROSS CAREL Secondary Insurance:
Date of Amount
Service Description of Services Charges Payments Adjustments Due 08/22/24 99285 EMERGENCY DEPT VISIT HIGH MDM $1,224.00
09/23/24 CARRIER PAYMENT $179.10—
09/23/24 CARRIER ADJUSTMENT $704.73-
THE BALANCE OF THIS ACCOUNT REPRESENTS YOUR CO-PAY, DEDUCTIBLE AND/OR NON-COVERED SERVICES. YOUR ACCOUNT IS 30 DAYS PAST DUE. PLEASE REMIT PAYMENT.
EL SALDO DE ESTA CUENTA REPRESENTA SU COPAGO,
(5 DEDUCIBLE O SERVICIOS NO CUBIERTOS. SU CUENTA TIENE 30 DIAS AL COBRO. FAVOR DE REMITIR SU PAGO.
FINAL NOTICE
If uninsured or with high medical expenses, you may qualify for a discount, payment plan or submit tomation via our secure portal a worasiane. lem or have insurance opt arm and submit it to [email protected]
Contact Us AMOUNT
[email protected] DUE
or
(800) 498-7157 $340.17
[email protected]
6 am - 5:30 pm PST
Please detach and return the bottom portion with payment VITUBIL2-1085053-0000000-18100790-601-001735-#002380-0994 epayitonline.com
CEP AMERICA CALIFORNIA Easiest way to view your statement, PO BOX 582663 make payments, set up a payment plan
MODESTO CA 95358-0046 or submit insurance information
vituity® STATEMENT DATE ACCOUNT $ OCHET DUE"
At the heart of better cane 11/04/24 E80 1214509 $340.17 Patient: MAIDA BARRIOS
•Please check box if address is incorrect or insurance information has changed and indicate change(s) on reverse side.
MAKE CHECK PAYABLE AND REMIT TO:
02222
MAIDA BARRIOS CEP AMERICA CALIFORNIA
РО BOX 582663
MODESTO CA 95358-0046
11042400000034017E80001214509
ARROWHEAD
REGIONAL MEDICAL CENTER
400 North Pepper Avenue
Colton, CA 92324
This is not a bill. This is an itemization of hospital services for:
Patient: Barrios, Maida Hospital Account: 1001465013
Guarantor: Barrios, Maida 08/27/24
08/27/24
Address:
(б)
Coverage(s): Blue Cross Blue Shield - BCBS
Charges
Svc Dt Rev Code CPT(R/HCPCS Code Description Amount
08/27/2024 0260 96372 HC 207.00
INJECTION, THERAP/PROPH/DIAGNOST,
IM OR SUBCUT
08/27/2024 0320 72100 HC X-RAY LUMBAR SPINE 2/3 VW - XR 1 402.00 LUMBAR SPINE 2-3 VIEWS
08/27/2024 0320 73502 HC X-RAY EXAM HIP UNI 2-3 VIEWS - XR 1 402.00 HIP 2 OR 3 VW LEFT
08/27/2024 0320 73552 HO RADIOLOGIC EXAMINATION FEMUR 1 402.00 MINIMUM 2 VIEWS - XR FEMUR 2+ VW
ILT
08/27/2024 0450 99283 HO EMERGENCY DEPARTMENT LEVEL 1 1,433.00 3 VISIT MODERATE SEVERITY
08/27/2024 0636 J1885 KETOROLAC PER 15 MG 26.00
08/27/2024 0637 METHOCARBAMOL 500 MG TABLET 3.60
Total charges: 2,875.60
Payments and Adjustments
Date Description Amount
11/30/24 Blue Cross Blue Shield Payments -613.85
Non-covered: 2,261.75
09/24/24 Blue Cross Blue Shield Adjustments -790.78
Total payments and adjustments: -1,404.63
Current Hospital Account Balance: 1,470.97
Questions? Call:(877)818-0672 or Email: [email protected] Customer service representatives are available
Monday - Friday 8:30 AM to 4:00 PM (except holidays).
1 7
ARROWHEAD
REGIONAL MEDICAL CENTER
400 North Pepper Avenue
Colton, CA 92324
This is not a bill. This is an itemization of hospital services for:
Patient: Barrios, Maida Hospital Account: 1001456026
Guarantor: Barrios, Maida Admission Date: 08/22/24
Discharge Date: 08/22/24
Address:
Coverage(s): Blue Cross Blue Shield - BCBS
Charges
Svc Di Rev Code CPT(R/HCPCS Code Description Amount
08/22/2024 0320 72072 HC X-RAY THORACIC SPINE+SWIM 3 402.00 VW - XR THORACIC SPINE 3 VIEWS
08/22/2024 0320 73130 HC X-RAY HAND 3+ VW - XR HAND 3+ 1 402.00
VIEWS LEFT
08/22/2024 0351 70450 HC CT SCAN,HEAD/BRAIN, W/O 1 3,202.00
CONTRAST MATL - CT HEAD WO
CONTRAST
08/22/2024 0351 G1004 HO RADIOLOGY CLINICAL DECISION 1 0.01
SUPPORT MECHANISM - NATIONAL
DECISION SUPPORT COMPANY
08/22/2024 0352 72125 HC CT SCAN, CERVICAL SPINE, WIO 1 3,202.00
CONTRAST - CT CERVICAL SPINE WO
CONTRAST
08/22/2024 0450 99283 HC EMERGENCY DEPARTMENT LEVEL 1 1,433.00 3 VISIT MODERATE SEVERITY
08/22/2024 0637 HYDROCODONE-ACETAMINOPHEN 5- 1 3.60
325 MG TABLET
08/22/2024 0637 METHOCARBAMOL 750 MG TABLET 1 3.60
Total charges: 8,648.21
Payments and Adjustments
Date Description Amount
12/12/24 Blue Cross Blue Shield Payments 2,326.38
Non-covered: 6,321.83
09/13/24 Blue Cross Blue Shield Adjustments -2,378.25
Total payments and adjustments: -4,704.63
Current Hospital Account Balance: 3,943.58
Questions? Call: (877)818-0672 or Email: [email protected] Customer service representatives are available
Monday - Friday 8:30 AM to 4:00 PM (except holidays).
1 ."..
THIS IS YOUR DIRECT DEROSIT RECEIPT 33726937
Amount
08/22/24 $294.77
---------
Iwo Hundred Ninety-Four and 77/100 Dolla
00878 010
MAIDA BARRIOS
Rainbow USA, InC Pay Period: 08/11/2024 - 08/17/2024 26937 BARRIOS, MAIDA SSN: XXX-XX-9818 Employee Number: XXXXX9818 Hours Rate Amount | YTD Amount Deductions| Amount YTD Amount Wages
REGULAR 21.15 |16.000| 338.40| 12977.27 CA 50.49
PTO 208.00 CADI 3.72| 145.66
OVERTIME 49.44| FIT 14.03| 668.61
RETRO 6.89| MEDE 4.90| 192.00|
m'ssed SSEE 20.98| 820.98|
WaRi
¡Total 21.15 338.40 13241.60
[Taxable Gross 338.40 13241.60
$294.77 $11363.86 43.63 1877. 74]
Net Pay
ACH PAYROLLI Acct 5632 294. 77|
Address: 1000 Pennsylvania Ave, Brooklyn, NY 11207 (718) 485-3000 Your available PTO is 18.00 hours and accrued PTO is 26.00 hours as of 08/17/2024. she shouldn't have to use
her pay time off for this
E-MAIL DIRECT DEPOSIT RECEIPT
-
THIS IS YOUR DIRECT DEPOSIT RECEIPT 33735512
Amount
08/29/24 $382.47
Three Hundred Eighty-Iwo and 47/100 Dollars------------
MAIDA BARRIOS
Rainbow USA, Inc Pay Period: 08/18/2024 - 08/24/2024 35512 BARRIOS, MAIDA SSN: XXX-XX-9818 Employee Number: XXXXX9818 Wages Hours Rate Amount | YTD Amount Deductions| Amount | YTD Amount |
14.00 16.000 224.00) 432.00 CA 2.38| 52. 87|
REGULAR | 13.33 |16.000 | 213.28| 13190.55| CADI 4.95| 150.61| OVERTIME| 0.53 (24.000) 12.72| 62.16 | FIT 25.77| 694.38|
6.89| MEDE 6.53j 198.53|
RETRO 27.901
SSEE 848.88
| Total 27.86 450.00l 13691.60
|Taxable Gross 450.00 13691.60
[Net Pay $382.47 $11746.33 67.53 1945.271
ACH PAYROLL Acct 5632 382.47l
Address: 1000 Pennsylvania Ave, Brooklyn, NY 11207 (718) 485-3000 Your available PTO is 5.00 hours and accruad PTO: is 27.00 hours as of 08/24/2024. she shouldn't Have to
Use Her tinse time of for this.
E-MAIL DIRECT DEPOSIT RECEIPT
Employee Attendance Record With Summaries
Name Barrios, Maida Hire Date 3/20/2008
Start Date End Date Ca Position Perc Hrs Mos WrkL
3/20/2008 10/14/2015 CL Instr Aide/SPED | 75.00% 9 DO
10/15/2015 8/13/2017 CL Instr Aide/SPED | 75.00% 9 AD
8/14/2017 8/11/2019 CL Instr Aide/SPED I!I 75.00% 9 AD
8/12/2019 Instr Aide/SPED I!! 75.00% 9 DHS
2024-2025
End Date AttCd SHrs SBal VHrs VBal Days DKT
/Date
17/1/2024 ADV +54.00 324.25| +120.00 240.00 20
18/22/2024 8/23/2024.S -12.00 312.25
8/26/2024 8/27/2024 S -12.00 300.25
19/10/2024 9/11/2024 PN -12.00 288.25
19/19/2024 9/20/2024 PN -12.00 276.25
10/14/2024 PB
110/21/2024 10/22/2024 PN -12.00 264.25
111/7/2024 -1.00: 263.251 ... 0.167
10/2024 1027/2024 -18.00 222.00
j 2024-2025 Totals
Personal Business PB
Personal Neccesity PN -36.00
Personal Illness S -25.00 4.167
Vacation V -18.00
Total -61.00 -18.00 14.2
$ 612.50
She shouldn't have to use
Printed: 11/14/2024 8:02:09 AM Page: 1
her pay time off!