Case #GHC0089553
CITY OF RIALTO CICERS DATE STAME
Y OF RIALTO
LIABILITY 2025 JAN 28
E AM 9: 53
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
1. Claims for deat, injury to person, or to personal property must be filed not later than six (6) months affer 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 §911.2).
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:
Adam Fabian Loza Garcia
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
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: Oct. 4th 2025 TIME: 1:49
DAM EPM
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.
I Was cooning and heard a "Crash and my neighbor Alma Called that a tree Fell on my Car I went outside to see and saw the tree on the left side of my car parked on the street by my home on
3. HOW DID DAMAGE OR INJURY OCCUR?, Jackson st Rialto
they took a Report and. I
my Car
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.
Rialto Ca 92376 City tree tell on my Car whie
panel. on street by my house.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2708.96 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 10-00-25 Amount: $ 2, 035. 52
Item/Date: 10-18-25 Amount: $2 2,708.96
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: s2708-96 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Iter/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) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: L 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
• ADDRESS: ADDRESS:
TELEPHONE: L) TELEPHONE: L 1
DATE: TIME: DATE: _ TIME:
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. 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 then you first saw City/Town vehicle; location of City/Town vehicle al time of accident by "A-1" and location of yourself or your vehicle at the time of t 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
7 SIDEWALK
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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Adam Fabian Loza Garcia 01-28-26
TYPE OR PRINT NAME DATE
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 DIMILÜE UALITUANIM - NEARTLINI UF iNUIVI ULFULLO
LICENSE NUMBER REGISTRATION VALID FROM TYPE TYPE VEHICLE USE ENGINE NUMBER MISC 07/22/2025 TO 07122/2026 11 AUTO KL7 30
VEHICLE IDENTIFICATION NUMBER MAKE VLF CLASS "YR YR MODEL TYPE VEH DATE ISSUED PEEL + NISS AH 2024 2012 12 0712212025
BODY TYPE MODEL [DATE FIRST SOLD MP AX WC UNLADEN / G/ CGW TOTAL FEES PAID CC/ALCO STICKER INSTRUCTIONS 4D 2011 G $156 36/ 1) CLEAN SURFACE - SCRAPI
OFF ACCUMULATED STICKER:
(WILL NOT STICK IF WET OR DIRTY).
LIENHOLDER 2) REMOVE DECAL BY BENDIN
PAPER ALONG DOTTED LINI
) LIFT EDGE OF DECAL ANE
LOWLY PEE
• PLACE STICKER ON REAR PLATE
AS SHOWN BELOW:
W 00000 VEHICLES:
REGISTERED OWNER R 00138 In Top Right Corner | CALIFORNIA LOZA ADAM FABIAN L 00006 -
MOTORCYCLES ONLY:
CAL
$156.0 Right Hall of This Well
cel Card Station F 53.0
Total: $159.04
- Payment Type: AMEX
339-325951
MV Authoriale
rodit Caed Authortz ae 240022 IMPORTANT INSTRUCTIONS ON REVERSE SIDE