CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2025 MAY 28 PM12:48
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). GITY CLERA
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 9237 Address: 290 W. Rialto Ave., Rialto, CA 9237
CLAIMANT INFORMATION:
Andrew Joseph Ortiz
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
The Miller Law Group (626 ) 240-0714
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE 15 S. Raymond Ave., Pasadena, CA 91105
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 11/29/2024 TIME: 10:00 •AM 21PM
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.
The incident occurred on North Ayala Drive and Renaissance Place in the city of Rialto.
3. HOW DID DAMAGE OR INJURY OCCUR?
The damage and injuries occurred when law enforcement vehicles from the City of Rialto collided with the vehicle I was driving. Mr. Fabela, the passenger of the vehicle, and I had attended a car show. Officers arrived and instructed everyone to leave. We complied and exited. (Please see attached sheet).
4. WERE POLICE AT THE SCENE? /YES •NO WERE PARAMEDICS AT THE SCENE? •YES ENO
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.
The collision, caused by the Rialto Police Department, directly resulted in my injuries. Following the incident, I began experiencing neck and back pain, and symptoms consistent with whiplash.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ TBA 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 PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $.
Item/Date: 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: Ezekiel Noah Fabela NAME:
ADDRESS. ADDRESS:
TELEPHONE: TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Kaiser Permanente Ontario Medical Center NAME:
ADDRESS: 2995 South Vineyard Avenue, ADDRESS:
Ontario, CA 91761
TELEPHONE: (833) 574-2273 TELEPHONE: _)
DATE: 11/30/2024 TIME: 9:00 WAM 0 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
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
5 20 25
Garrett Miller
TYPE OR PRINT NAME DATE
Attorney
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 As we exited through the main gate of the parking lot, one officer followed us. At no point were sirens activated, nor were there any audible commands given through a loudspeaker or intercom instructing us to pull over. All the police units present had their lights activated, but we were unsure of the situation or their intentions.
We made two right turns, with the first onto Renaissance Parkway, then onto Ayala Drive. After the second turn, we activated our hazard lights. At that point, four police vehicles were behind us. Suddenly, one officer intentionally struck the driver's side of our vehicle, causing it to spin.
Immediately afterward, another police vehicle collided with the passenger side, and a third hit the rear of the car.