Docusign Envelope ID: 157BF279-6C63-410C-BOBD-794CA2DA043F
CITY CLERK'S DATE STAMP
CITY OF RIALTO
SANTO, CANE CITY OF RIALTO
LIABILITY
2025 MAR - 3 PM 3:25
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:
Franklin Luces Rojas Jr.
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/A
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:_12/31/2024 TIME: 8:00 •AM X 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.
Parking lot located: 1312 E. Ontario Ave. Corona, CA 92881
3. HOW DID DAMAGE OR INJURY OCCUR?
I was entering the mall parking lot when the officer driving an un-marked white patrol unit, reversed out of a parking space and collided with the rear right passenger door, tire and fender, causing significant damage to my vehicle.
4. WERE POLICE AT THE SCENE? X YES • NO WERE PARAMEDICS AT THE SCENE? • YES IX 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 officer driving an un-marked patrol unit
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ Unknown 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: $
Docusign Envelope ID: 157BF279-6C63-410C-B0BD-794CA2DA043F TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CAN RIALTO $ Pending ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 2025 MAR - 3 PM 3:42ount: $.
Item/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) NAME: Corona Police Department Traffic Collision Report attached. NAME:
ADDRESS: ADDRESS: _
TELEPHONE: (_ ) TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: — Pending NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: | )
DATE: TIME: ШАМ I PM DATE: TIME: • AM OPM
9. PLEASE READ THE FOLLOWING CAREFULLY:
or all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate plac f accident by "X" and by showing house numbers or distances to street corners 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
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE —Fimado GERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIONAFERRE @RE SEA MANT OR AGENT
_Franklin Luces Rojas Jr. 02/04/2025
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 Culver Legal LLP US POSTA
5670 Wilshire Boulevard FIRST- CLASS
Suite #1370
Los Angeles. CA 90036 P 9003฿
9589 0710 5270 0208 1155 41
700165703
CITY OF RIALTO 2025 MAR - 3 PM 3: 25 ECEIVE TY CLEF Rialto City Clerk's Office 150 S. Palm Ave..
Rialto, CA 92376