CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2025 MAR - 6 PM 12: 02
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:
KALL FREDERICK KALODZIK
FULL NAME DATE OF BIRTH
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 SAMA AS ABOUT
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 7AUG /972 - Z8DFC 199TIME: 27/½485 DAMOPM
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.
EMPLOYKE (FIRA CAPTAIN) RAD
3. HOW DID DAMAGE OR INJURY OCCUR?
NEUR CASHED OUT ON SICKTIMA PAY OUT
4. WERE POLICE AT THE SCENE? EYES ANO WERE AT AT THE SCENE? COYES ANO
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.
TO CORRECT SHORTAGE IN FINAL COMPRNSATION
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $73,024) HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: SEE FINAL COMPENSATION SLIP Amount: $ 73,420 8$ Item/Date:
Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $73,42480 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: N/A Amount: $
Item/Date: NZA 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: CHIEF BRIAN PARK NAME: GEOFF BARRETT
ADDRESS: 13/ 5. Willow AUR ADDRESS:
RIALTO, CA 92376 -
TELEPHONE: TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: _ NAME: N/A
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: 1. 1
DATE: TIME:
DATE: _TIME:
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 place of accident by "X' and by showing house numbers or distances to street comers ccident 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 IOR NECI AREL INNED DEMIALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT ORJAGENT
KARL F KoloDZIK EMARCH 2Q25
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 CALIFO Bank of America
16.66 CITY OF RIALTO Southern CA. Government Check No. 2666 1220 Services Dry 1431
150 SO. PALM AVENUE Los Angeles, CA 90071 Dept. Empl. # Date RIALTO, CA 92376
5174 12/24/1999
Amount
PAY EXACTLY **** VOID **** VOID **** VOID **** VOID **** ********0.00 PAY 7
KARL KOLODZIK
TO THE
ORDER 100 68
OF
L J
CITY OF RIAr.TO
Empl. Name KARL KOLODZIK Pay Period START Date 12/05/1999 Gross Pay 1.811 02 Empl. Number Pay Period END Date
12/18/1999 Net Pay 100.68
CHECK# 2666 Issue Date 12/24/1999 Filing Status M 02 Taxable Calendar Y-T-D Earnings 98.264.52
EARNINGS BENEFITS DEDUCTIONS
Description Hours Rate Amount Description Amount Year-To-Date Amount Year-To-Date.
HOURLY P44
u a 405. 87 FEDERAL WI 122.74 16117.0
oto 58.00 21.431 1242. 99STATE WITH 15 28 4880
sep 62.00 PERS 338.48 8416.65
hmp 1.00/100.000 100 O0SURVIVOR'S 0.93 16 . 7
edpa 62 16LIFE INSUR 39.30
KAISER +2 1158.18
* TOTALS* 121.00 14.967 1811. O2DENTICARE 71.97
GREAT WEST 307 7999 9
KAISER +2 46.25 560 0
ALLIANCE Pi 34.20 802.0
VISION PLA 171 0
JARROWHEAD 1100.00 28100.0
RIALTO FIR 41.25 418 5
42.00 1008.0
* TOTALS* 338.48 9686. 10/1710.34 60103 5
LEAVE
Description Taken Earned *Balance
SICK LEA 4.89 2894.07
compensa 38 5 0
holiday 49.93
VACATION 9.79 420.78
34$7.21 X 71.43/ = 73, Ø2.ФФ
COMMENTS: HAPPY HOLIDAYS TO YOU!!