CITY CLERK'S DATE STAMP
CITY OF RIALTO
OF RIALITO CALIFO
LIABILITY
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2025 NOV 25 CITY OF
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). AM RIAL
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: FE
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Offide
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Riste CA 92376 Address: 290 W. Rialto Ave. Rialto, CA 92376
CLAIMANT INFORMATION:
Millie Rose Pedraza
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TÉLEPHONE NO.
NA
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Westphal Law Group, 1881 Commercenter East, Ste. 210
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): San Bernardino, Ca. 92408
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: September 25, 2025 TIME: 9:40 • AM & 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.
The sidewalk in front of 750 N. Belden Avenue, Rialto, CA. 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
A concrete slab in the sidewalk was greatly lifted causing a dangerous condition. When Millie Rose Pedraza was walking on the sidewalk she tripped and fell because of the lift in the sidewalk. See pictures of sidewalk attached
4. WERE POLICE AT THE SCENE? • YES & NO WERE PARAMEDICS AT THE SCENE? **YES • NO
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 City of Rialto should have repaired the sidewalk, warned of the dangerous condition and provided better lighting in the area before claimant's accident occurred. It was very dark when the accident occurred and the lift in the sidewalk could not easily be seen.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage §ee Government Code 910 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE: Per Government Code 910, no dollar amount is stated. This claim is in the Item/Date: unlimited civil jurisdiction of the Superior Court. Amount: $ Item/Date: Claimant suffered a displaced transverse fracture of the Amount: $ right patella as a result of tripping over the lift in the sidewalk which requred surgery. and hospitalization. See photo of claimant attached.
Paao 1o85 Attorney
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) • Jayden Pedraza (9 years old) NAME:
NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) NA TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: Arrowhead Regional Medical Center NAME: Grand Terrace Healthcare Center ADDRESS: , 400 Pepper Avenue ADDRESS: 12000 Mount Vernon Avenue Colton, CA. 92324 Grand Terrace, CA. 92313
TELEPHONE: (909 580-1000 TELEPHONE: 909) 825-5221
DATE: 9-25-25for 5 daysTIME: 10:00 DAM X*PM DATE10/1/25 to 10/25/25 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.
EFFEYERK NOV 25 CITY OF RIALTO
CURB
AM/O: 39
PARKWAY
SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUI I CERTIFY (OR DEÇLAREYUNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT 1
Wesley B. Westphal 11/24/25
TYPE OR PRINT NAME DATE
Attorney for Claimant
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 Paad. Inf5
11/24/25, 6:01 PM 750 N Belden Ave - Google Maps
CITY CLE RECEIVE 2025 NOV 25 AM CITY OF RIA
Page Yo8 5 Aftarner for Claimant
https://www.google.com/maps/@34.1126643,-117.3495483,3a, 37.5y, 270.07h, 81.24t/data=13m711e113m511svgAyZyww8Cj25b49yqAQ12e016shttps 2/3 11/24/25, 6:00 PM 760 N Belden Ave - Google Maps
CITY CLERK RECEIVED 2025 NOV 25 AM 10:41 CITY OF RIALTO Roch Mhen
https://www.google.com/maps/@34.1127568,-117.3495477,3a, 37.5y,234.42h,85.11t/data-13m711e113m5|1sPMqq5NkGUuZrfQ7-NvpGrg!2e016shttps:.. 2/3 2025 NOV 25 AM IO: 41 CITY OF RIALTO
'! long for Comet.