CITY CLERK'S DATE STAMP
CITY OF RIALTO
ALANHO, CALE CITY OF RIALTO
LIABILITY
2025 JUL 28 AMIO: 58
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECDIYLL
CITY CLERA
1. Claims for death, injury to person, orto 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 5911.2). RETURN TO:
3.READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office Mail: 150 S. Palm Ave., Riallo, CA 92376
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Address: 290 W. Rialto Ave., Rialto, CA 92376 CLAIMANT INFORMATION:
EDUARDO BENITEZ DATE OF BIRTH
FULL NAME
1- -
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: JULY 10 2025 TIME:NOON 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.
Sycamore by madrona
3. HOW DID DAMAGE OR INJURY OCCUR?,
THE SHOCK JUST DROP
4. WERE POLICE AT THE SCENE? DYES IZNO WERE PARAMEDICS AT THE SCENE? DYES 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 SHOCK DROPPED IN SICAMORE BY MADRONA IN RIALTO
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 2 FRONT STRUTS $ I ALIGNMENT Amount: $640
Item/Date: STRUT AND COIL SPRING ASSEMBLI Amount: $ 956.57 PARTS| SUPPLIES
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1956,57 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 7-25-2025 Amount: $ 956.57
Hem/Date: 7-25 - 2025 Amount: $ $ 640
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 956•57
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME: _
ADDRESS:
ADDRESS: _
TELEPHONE: L TELEPHONE: 1)
DATE: TIME:
DATE: TIME: DAM DIPM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehice 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 cityftown 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 MADRONA
INCAMORE PARKWAY
SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
EDUARDO BENITEZ 07/28/2025
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 STOP
ST
300
@MADRONA
STOP
CALIFORNIA TIRES
510 E. Foothill Bivd. Rialto, CA 92376
(909) 640-7009
MODEL DATE
YEAR00 8 make Muzda 1757025
LICENSE PLATE CASH CHARGE
SALESMAN Pace
NAME PHONE
ADDRESS CITY ZIP
VALVE STEM • ALIGNMENT 1UTIRE 3UJTIRE SPECIAL ORDER MILES BALANCE • DISPOSAL • BRAKES 20 TIRE 40 TIRE L OTHER
QTY DESCRIPTION TOTAL
2 Frant Struts
1 Alicuama +
VISA FEE
PARTS
LABOR
Quate SUB-TOTAL
TAX
any other cause beyond our control. Calfornia Tires is not responsible for lost, damaged or defective rims, lug nuts or hub caps. тотА $640 FACTORY TIRE WARRANTY: To validate your warranty every 3 months rotation and alignment 2 times per year, DEPOSIT If no proof the guarantee is lost.
BALANCE
THANK YOU
Authorized Signature
MT 19:26
RIALTO AUTO CARE CENTER ESTIMATE #
135 E. FOOTHILL BLVD 434245
RIALTO, CA. 92376
Phone: 909-877-5446 Fax: 909-877-3829 ARD00269174
CAL000440415
Estimate for Services Estimate Date: 7/25/2025
BENITEZ, EDUARDO 2008 Mazda - 3 s Grand Touring - 2.3L, In-Line4 (138C1) VIN(< Lic#: Odom. In: 0
Rialto, CA 92376
Cellular: VIN # :
Part Description / Number Qty Sale Ext Labor Description Hours Extended
1.00 267.78 267.78 SHOCK &/OR STRUT ASSEMBLY - Remove & 2.30 379.50 Strut And Coil Spring Assembly Install or Remove & Replace - Both Sides. - 33MZ1107 [DOES NOT include disassemble or alignment.]
Strut And Coil Spring Assembly 1.00 267.78 267.78
33MZ1108
HazMat/Fees: 0.00 Tax: 41.51 Total: $ 956.57
Parts/Supplies: 535.56 Labor: 379.50
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permission to operate the vehicle described for testing and/or inspection. Express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto.
SMOG: I understand that I can have emission service and/or adjustments done elsewhere. I hereby waive this right.
TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within_ recommended. All Parts removed will be discarded unless instructed otherwise:
Signature