CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2025 DEC 11 PM |: 18
TO PERSON OR PROPERTY RECEIVED
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 §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:
David Ezrah Lingurar
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 Injury legal center
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): 2922 Daimler st. Santa Ana CA, 92705
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 6e 24 25 TIME: 7:45 #AMOPM
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.
Riversial Are North of 1-10 WB
3. HOW DID DAMAGE OR INJURY OCCUR?
our client turned right on riverside or went to #2 lane came to a stop due to traffic when was rear-ended by defendant.
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.
David Padilla, city of Rialto P.D
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 54,008.14 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: repair estimate Amount: $ 2,318:14
Item/Date: médical bills Amount: $51,690
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 350;000
CITY OF RIALTO
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: prospective medioc expenses 2025 DEC |1 PM I: Anfount: $ 15,000 Item/Date: Amount: $
RECEIVED
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: CITY CLERK $15.000
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: N/A NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: (
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: 1E Injury care NAME: Southern California orthopedic 3 kena specialist
ADDRESS: 6800 Indiana Are Ste. 280 ADDRESS: 3420 Bristol St ste 700 Riverside CA, 9250l Costa mesa cA, 92l24
TELEPHONE: (951) 7839198 TELEPHONE: 214) 485-3599
DATE: (8/24/25 - present TIME: •AM • PM DATE 81|25- present TIME: •AM OPM
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
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 TRUE I CERTIEY IOR NECI ARE INNER PENAI TY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. _SIGNATURE OF CLAIMANT OR AGENT
Giovanni Chavez 12-8-25
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
CITY OF RIALTO
2025 DEC 11 PM |: 18
RECEIVED
CLAIMANT'S DESIGNATION OF ATTORNEYCITY CLERK
Signed this _25 day of Juns 2025.
Signature
David Lingurar
Name-Printed
Social Security
Signature of Parent or Guardian
(Ad Lit Litem)(if applicable)
92376-648799
RIALTO CA 92376-6406
150 S PALM AVE
RIALTO CITY CLERK'S OFFICE
CITY CLERK RECEIVLU 2025 CEC | / PM |: | S CITY OF RIALTO 9589 0710 5270 2642 0804 16
DEC 09 2025
ZIP 92705 C 2025 5M 7 L
SANTA ANA CA 92705-5801
FIRST-CLASS A ANA CA 926 2922 DAIMLER ST
US POSTAGEm
$10.440 INJURY LEGAL CENTER
PITNEY BOWES
CERTIFIED MAIL