CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES
2025 NOV 12 PM 3:57
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
1. Claims for death, injury lo person, or to personal property must be filled 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 §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 INFORMATION:
Andrew James Quezada
DATE OF BIRTH
FULL NAME
-
IOME ADDRESS INCLUDING CiTY, STATE & ZIR 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: 10/24/2085 TIME: 5:30 DAMERM
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.
Intersection of riverside and merrill, I was arrested for driving withat a lifense, and elen though mu mother,
a willing, licensed person I asked they release mu car to
HOW DID DAMAGE OR INJURY OCCUR
Since haying ma car tawed I've struggled to get
to wark (mu start time is 4a.m.) resultina - an un-
necessary strain, loss of income, additional hardship.
4. WERE POLICE AT THE SCENE? TOYES DINO WERE PARAMEDICS AT THE SCENE? • YES XONO
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 knowr
Rialto Police Officer E. Camacho Rivas I.D.# 02750
car to a willingand abled third
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 4,000.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Police release fam fee Amount: $ 216:0
Item/Date:
taving and Sterage fee Amount: $ 1,502"
Item/Date:
100.%
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY OF RIALTO 100.0
Item/Date: bus, carpooling, lyft 2025 NOV12 PM
Item/Date: _ pain and sutfenrg
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Marina Newman NAME: Eric Gonzales
ADDRESS: ADDRESS:
colton CA.
TELEPHONE: TELEPHONE: _
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: ()
DATE: TIME: • AM •] PM
DATE: TIME • AM 0] 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 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 SIT A TON, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT, CURB
PARKWAY
7/1 SIDEWALK
AVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS IOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF: AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRI I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
AGNATURE OF CLAIMANT OR AGENT
Andrew vames Quezada 11/04/2025
YPE OR PRINT NAME DATE
Self
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 continued...
2) and who even mu mother day, hod the total aved
nerself asked the police ottias wata be 2 to 82, 06, m
if she cauld please drive the
car home, the officers there and Suffering and 10ss of
refused to release the car
to my mother and proceeded corave been axeided na
placed under a 30 day hold.
and not once was t informed
of where my car would tawd
to or given any information
on hau to retrieve It.
5.) 3an day hold, when per
thirdypert present to
the vehiclesto, then that remove
the neth victors a sing
dest 504 to tet total
as 1, 562t tacing fee storage
there's another galle for the
release farm, after the 30
SN DERNARDINO CA. 323
nm Andrau Guera da s
10 NOV 2025 PM 7 L
CITY OF RIALTO 2025 NOV 12 PM 3: 56 RECEIVED
To: Rialto Cit Clerk'S
office uth rumALe
Ready Post. RiCiNO CA. 92376
Document Mailer
92376-640650