201
CITY CLERK'S DATE STAMP
CITY OF RIALTO AUG
4 n
LIABILITY
21 CITY OF RIALTO
CLAIM FOR DAMAGES
PH
TO PERSON OR PROPERTY
1 Claims for death, jury lo person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code 5911.2). 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 Aires 250W. Rairo Ave. Ratio. CA92376
CLAIMANT INFORMATION:
Carolyn Langan
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 660 S. Figueroa St., Sky Lobby, Los Angeles, CA 90017
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 02124/2025 TIME: 12:30-1:30 DAM LA 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.
Rialto Middle School -1262 W Rialto Ave, Rialto, CA 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Claimant was punched in the face and head by another student in class. The other student also grabbed Claimant's hair & dragged her to the floor while continuing to kick and punch her. This is not the first time Claimant has been attacked in this district. The teacher in the classroom stood and watched, without intervening.
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.
Rialto Middle School
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ TBD HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, elc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: Dignity Health - Community Hospital of San Bernardino Amount: $_ $22,475.00 Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: TBD ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Pain and Suffering Amount: $ $10,000,000.00
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: TBD
$.
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Christine Haynes NAME:
ADDRESS: ADDRESS:
TELEPHONE: - TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Dignity Health - Community Hospital of San Bernardino NAME:
ADDRESS: 1805 Medical Center Dr. ADDRESS:
San Bernardino, CA 92411
TELEPHONE: (909) 887-6333 TELEPHONE: | |
DATE:02/24/2025 TIME: DATE: TIME:
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. 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 vehic hen 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 th 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
THOSE MEAT ERE MORE ARE IN TAE UPON ONE TO AND ARE AND AS TO THOSE MATERS BE EVE THEM TO BE TRUE XCEPT ASTO I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Ryan Cowan, Esq. 08/21/2025
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