CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2025 MAY 29 AMIO: 13
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECOIVEL
CITY CLERA
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months afler 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 INFORMAȚION:
DATE OF BIRTH
FULL NAME
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
7T
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: June 6-2024 TIME: 10:00 HAM DIPM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate giye street names and addresses, measurements and landmarks.
TAXE 330
3. HOW DID DAMAGE OR MURY OCCUR?, Bad Road Condition see
4. WERE POLICE AT THE SCENE? • YES D 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 employee causing the injury or damage, if known.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 536.81 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
June 6, 2024 Amount: $534.81
Item/Date: 2-
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 536.81 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 11-25 - 2024 Amount: $ 536.81
Item/Date: //- 25- 2024 Amount: $/ 761. 3)
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $2293.12
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: L 1
DATE: TIME: DATE: TIME: DAM 0PM
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 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
PARAMAN Riveside Avi
7 SIDEWAL OUTL
Resorcef
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. / I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
DAVID VANCE PeFAS May 26,0025
TYPE OR PRINT NAME
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
GEORGE HILLS
CITY OF RIALTO
2025 MAY 29 AMIO: 12
RECEIVE.
CITY CLERA
March 31, 2025
David Rojas
11424 Leatherleaf Rd.
Fontana, CA 92337-1420
RE: Our Client: City of Rialto
Claim Number: GHC0079507
Date of Loss: June 6, 2024
Dear David Rojas,
George Hills is the liability claims administrator for the City of Rialto. It is our function to review claims on behalf of the city and provide recommendations regarding them.
After completing our review of the referenced incident, we have determined that your claim should be rejected, as the required burden of proof to establish fault against the city has not been met.
You will be receiving a formal rejection notice which will provide additional information regarding your claim.
If you have any questions, please contact the undersigned.
Kindest Regards,
George Hills Company
cumul dara
Cynthia Lara
Claims Representative
Phone: (909) 632-4134
Email: [email protected]
CC: City of Rialto
P.O. BOX 278, RANCHO CORDOVA, CA 95741
a picture in
Worth a Thorand
Nirds.
claim Number, +9H40079507
CITT OF RIALTO 7025 MAY 20 CD: 12 CITY CLERA
say 25-2025
Dongon Rinside AV
This is a Pucture to
entry to 330 FedEx
Kurtary lot. One Alich
lookny wat
Invoice - Customer Copy - Page 2
Pep Boy! '07
(oralla- 6, 2024
PEP BOYS AUTO # 680 June
16711 VALLEY BLVD Brakes
16711 VALLEY BLVD
FONTANA, CA 92335 Front
(909) 823-7131 $536.81
BAR# ARD303408
EPA# CAL000082946
TRACKING ID#*
Service Manager: ANDY MEDRANO
Store ID # Service Work Order #
Insurance : If you have any questions 0680 2251998
or concerns, please call:
Policy Number: (909) 823-7131
Name: DAVID ROJAS Year: 2007 Date: 2024-06-06
Address: Make: TOYOTA Entered By: ANDY M
City: Model: COROLLA Time In: 08:38:08
State: Engine: 4-1794 1.8L 1ZZ-FE Dato/Time Promised: 2024-06-06 11:53:20 Zip: Vin No.: Old Parts Returned: no
Home Phone: License No:
Contact Phone: Mileage: 75124 Customer Waiting
Color:
I HEREBY AUTHORIZE PEP BOYS TO PERFORM THE REPARS ON THIS WORK CRDER AND TO FURNISH THE NECESSARY MATERIALS AND ITS EMPLOYEES TO OPERATE THE VEHICLE FOR PURPOSES OF INSPECTION. TESTI DELVERY. I UNDERSTAND THAT ANY COST QUOTED IS AN ESTIMATE I UNDERSTAND THAT UNLESS DIRECTLY CAUSED BY PEP BOYS, ITIS NOT RESPONSIBLE FOR ANY LOSS OR DAMICE TO THE VEHICLE OR ITS CONTENT THAT THE VEHICLE MAY BE PARKED IN THE PEP BOYS PARKING LOT AND THAT VEHICLES ARE LEFT OVERNIGHT AT OWNER'S RISK.
X
Initial Estimate Parts $: Labor $: Total $: Date and Time:
317.28 194.69 536.81 2024-06-06 08:38:08
I acknowledge notice and oral approval of an increase in the original estimated price (signature or initials)
TYPE PART DESCRIPTION CODE MECHANIC HRLY HR$ aTY SOURCE EACH TOTAL PK 0068510 FRONT ROTORS) PKG
LB ERICH 0.00 0.00
FRONT ROTORRUNS WITH BRAKE SEANCE N
PN 31270G F DISC BRAKE ROTOR 140.99 281.98
LIMITED TWO YEAR WARRANTY
Package SubTotal : 281.98
PK 4635105
LB FRONT BRAKES LABOR ERICH 175.00 143.75
POSTTENDER: -31.25
PN PSG923 F DISC PADS N 34.99 28.74
POSTTENDER - -6.25.
LIMITED LIFETIME WARRANTY
L.B BRAKE FLUID CHANGE LABOR N ERICH 1 62.01 50.94
PÖSTTENDER -11.07
PN 00120 MAG1 DOT3 BRAKE FLUID 320Z N 7.99 6.56
POSTTENDER -1.42
Package SubTotal : 229.99
SF 2688 ENVIRONMENTAI. HAZARDOUS WASTE FEE N 0.25 0.25
LB COMPLIMENTARY VEHICLE INSPECTION ERIC H 0.00 0.00
LB BRAKE SYSTEM INSPECTION N ERICH 0.00 0.00
Parts: 317.28 Labor: 194.69 Other: 0.25 Tax : 24.59 Total : 536.81 Tender Date : 06/06/2024 Tender Time: 11:57 AM
POS Trans # : 126794 Store: 0680
Tender Register: 105 Tender Till #: 105
Tender Cashier: 492624
NEED A TOW? CALL 1-800-PEP-BOYS or
800-PEP-BOYS 1-800-737-2697