CITY CLERK'S DATE STAUP
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES
2025 AUG 29 CITTO
TO PERSON OR PROPERTY
1. Obies for decle, injury do parson, or to personal property must be fled al lator than sir (5) mcnal aler la Occasanca (Gor Codo $011.2).
2. Claims for damages to road property must be filed not tater than one (1) year alter the accurance (Gov. Code $911.2). RETURN TO:
3. READ ENTIRE CLAM FOR BEFORE FLING Rialto City Clert's Office F3
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mait: 150 S. Pain Ava, Pollo, CA 92376.
Address: 290 W. Risto Ave., Rielto, CA 92376
CLAIMANT INFORMATION:
MICHAEL WHITE SR
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CY, STATE & ZIP HOME TELEPHONE NO.
NIA L ) NIA
BUSINESS ADDRESS INCLUDING CITY, STATE & 2P BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECENE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if diferent from home address provided above):
1. WHEN DID DAMAGE OR ILURY OCCUR? DATE: 06 - 13 / 14 - 25 TE: 09AM - 5PM DAM 17PM 2 PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Dascribe fully and (if applicalla) locate on diagram on revarse side of this sheet Where appropriale, give stroal names and addresses, measurements and landmarks.
VINES SATURATED THE FENCE ON RANDAL - SOUTH SIDE OF PROPERTY - MAITANENCE VINE REMOVAL
CAUSED FENCE BODY AND FENCE APEX DAMAGE - REPAIR IS NEEDED
TO STRENGTHEN THE STRUCTURE AND REPAIR THE OBLITERATED TOP (ATTACHE PHOTOS)
3. HOW DID DAMAGE OR INJURY OCCUR?
SOUTH FENCE DAMAGE DURING A RIALTO CITY SCHEDULED CREW MAITANENCE VINE REMOVAL
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? DYES NO
5. WHAT PARTICULAR ACT OR OMISBION DO YOU CLAIM CAUSED THE JURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
RIALTO CITY MAINTANENCE ACTIVITY OF VINE REMOVAL
&. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ TBD - ATTACHED HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, rapair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: Amount $ TB D - ATTACHED
Item/Date: Amount: $_
•
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ TBD ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWIE:
Horn/Defe: Amount: $.
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $.
7. WITNESSES TO DAMAGE OR INJURY List all persons inom to have information (illact editional pages, i necessary) NAME: MICHAEL WHITE SR NAME: STEPHANIE EDWARDS WHITE
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: L L-
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: N/A RAME N/A
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE:
DATE: _ TIME: DATE: TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streats, including NORTH, EAST, SOUTH AND WEST directions, Indicate place of accident by "X" and by showing house numbers of 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 "8" location of yourself or your vehicle when you first saw City/Town vehicle; location of Cily/Town vehicle at tiese of accident by "A-1" and locallon of yourself or your vehicle at the times 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
PARIONAY
7 SIDEWALK
¡ HAVE READ THE FOREGOR CLARI AND IOOM THE CONTENTS THEROF, AND CERTFY THAT THE SAME IS TRUE OF MY CHAN IOOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREN STATED UPON MY INFORMATION AND BELIEF, AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE. " YCERT,/(OR DECLARE) UNDER PENALTY OF PERLURY THAT THE FOREGOING IS TRUE AND CORRECT,
SIGNATURE OF CLAIMANT OR AGENT
MICHAEL WHITE SR 07/09 / 2025
TYPE OR PRINT NAME DATE
HOME OWNERS
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72)