CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 DEC 18 PM 5:12
TO PERSON OR PROPERTY
CITY GLERK RECEIYED
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:
:
Marco Torres
FULL NAME DATE OF BIRTH
9454 Wishire Blud. PHro Beverly Hills, (A90212
HOME ADDRESS INCLUDING CITY, STATE & 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):
04/19/24 11:45 MAMOPM
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _ 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.
Theincident happened on Willow Avenue and foothill Blud.
3. HOW DID DAMAGE OR INJURY OCCUR?
Marlo torres was walking home when he fell due to
The water and tree roots on the broken side walk.
4. WERE POLICE AT THE SCENE? •YES/NO WERE PARAMEDICS AT THE SCENE? •YES NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town у as a dangerous condition by stung to fix the
have broken
part of the concrete.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ More than' 500, 0as HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTAȚION OF THIS CLAIM: Mace thAn 5os, ass ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
CITY OF BLALTO
Item/Date: Amount: 8024 DEC 18
Item/Date: Amount: $
PH 5:13
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
SATY REGEIVED
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) CLERK NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Dr. Eduardo Suarez NAME:
ADDRESS: ADDRESS:
TELEPHONE: L) TELEPHONE: L
DATE: TIME: • AM •PM 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 corners.
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.
CURB
PARKWAY
7 SIDEWALK
willow Are.
1 HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Ands Basseri 12-11.24
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 2000
U.S. POSTAGE PAID
FCM LETTER
9454 Wilshire Biva: PAZEITY OF RIALTO BEVERLY HILLS, CA 90212 DEC 11, 2024
Beverly Hills, In 9020840EC PM PM S:13 92376 $9.68
RECEIVED RDC 99 S2324E500299-83
9589 0710 5270 2361 5122 81 I CITY CLERK
PLACE STICKER AT TOP OF ENVELOPE TO THE RIGHT
CERTIFIED MAT®
Rialto Lity clerk oftice
150.5. Palm. Ave.
9989 00 00 0 Dialto, CAa9.2376