Docusign Envelope ID: 2A41E9CF-D975-4D2D-A361-9F567BB80A23
CITY CLERK'S DATE STAMP
CITY OF RIALTO
SANTO, CATE 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:
Rosmary A. Lopez Martinez
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 XI 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 a passenger when we enter 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: 2A41E9CF-D975-4D2D-A361-9F567BB80A23 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ Pending
CITY OF RIALTO
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 2025 MAR - 3 PM Amgant: $.
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 Depariment 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: | 1
DATE, TIME: • AM I PM DATE: TIME: •AM • PM
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 of 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
7/1 SIDEWALK
I 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 —Fimado bo! CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
STONATURE OPORAIMANT OR AGENT
_Rosmary A. Lopez Martinez 02/04/2025
TYPE OR PRINT NAME DATE
_I was the front passenger
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