CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY 2025 DEC -8 CITY OF RIALTO
CLAIM FOR DAMAGES : PM 5:26
TO PERSON OR PROPERTY RECEIVEL
CITY CLERK
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 5911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code 591112). 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. Riatto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Bryan Morales DATE OF BIRTH
FULL NAME
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: 09/15/2025 TIME: 11:07 pm DAMBPM
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.
Traffic Collision report. I was involve in a traffre collision on 09/15/2075 at 11:07pm.
The street were the car allen! happen was on foothill Bird & N Willow Ave. Rialto, A 42376, Some land mates ce a Sucks in the box in one corner, O-Rielly in one come, und Fill in one com 3? HOW DID DAMAGE OR INJURY OCCUR?
A white Dodge Ramn 1995 t-bone me on a white 2010 toyota Corolla, My car enlas up on the right sile of the door, I supatain a tramatic Brain Injury and other injuries indule frastare skull and riberge punsture lung and telency.
4. WERE POLICE AT THE SCENE? D/YES•NO WERE PARAMEDICS AT THE SCENE? DYES •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.
Police stution sent me to city clerk sinsepthey stated that my items were misplaced in transport from the location of the guant to the police station.
6. GIVE TOTAL AMOUNT OF CLAIM include estimate of amount of any prospective injury or damage $ 1,720 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Iphone Is po Amount: $ 1,090
Item/Date:
Laste Glasses Amount: $_220.00
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: = 1,720 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: b-shock Amount: $_180.00
Item/Date:_ Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $146.00
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: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
MANE: Arrow hend Regional Milient Center MAME: Loma Ling University Medical Centertant Campus ADDRESS: 400 N. Pepper Ave Colton, CA 92376 ADDRESS: 25333 Burton Rd Loma Linda, lA, 92354 TELEPHONE: (472) 873-2762 TELEPHONE: (904) 425-8601
DATE: 09/16/2025 TIME: 12:00 DATE: 09/2325 TIME: 8:30 DAME PH
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 citytown vehicle was involved, designate by letter "A" location of the City/Town vehicle when you fust saw it, and by "B' location of yourself or your vehicle when you first saw City/Town vehicle; location of City/Town wehicle 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.
Jack in O-Rielly
the boy outoparts
Trac Mycor
CURB
Thes stop
PARKWAY
SIDEWALK
7/11
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
ICERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Bryan Morales 12/08/25
TYPE OR PRINT NAME DATE
Myself
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