CITY OF RIALTO CITY CLERKS DATE STAND
LIABILITY
APR -5 PM: CITY OF RIAL
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY LERK
1. Claims for death, injury to person, orto personal property must be filed not later than six (6) months after the occurrence (Gov. Code 59112).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code 5911.2). RETURN TO:, Rialto City Clerk's Office
3.READ ENTIRE CLAIM FOR BEFORE FILING Mail: 150S. Palm Ave., Rallo, CA 92376
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Address: 290 W. Riato Ave., Rialto, CA 92376 CLAIMANT INFORMATION:
Izayah Jones
DATE OF BIRTH
FULL NAME
HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
TIME: _ 6:30 DAM APM
4. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 3/25/26
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 entrance gate to the Rialts PD parking lot.
3. HOW DID DAMAGE OR INJURY OCCURY,
Police officer didnt yeild when exiting the parkins
lot and strick me on my bike: sending me flying oft
my bike, and bike was damaged leaving it unrideable,
4. WERE POLICE AT THE SCENE? YESNO WERE PARAMEDICS AT THE SCENE? EYES 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.
Office S. Ford was the driver of the vehicle that
Struckime
4+00
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE: 1400
Amount: $
Item/Date: Electin
Amount: $_
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $400 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $.
Item/Date: Amount: S
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Officer N. Villarreal NAME: Rochelle doves
ADDRESS: Rialto P.D,
ADDRESS:
TELEPHONE: (_ ). TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
MANE: coma Linda
NAME:
ADDRESS: ADDRESS:
TELEPHONE: (90) 552-4444 TELEPHONE: L)
DATE: TIME: DAMO PM DATE:
TIME:
8. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident daims, 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' iocation of yourself or your vehicle when you first saw City/Town vehicle; location of City/Tom 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: & THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIIANT.
CURB
PARKWAY
7 SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS 1 HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
zayah Janes 4/3/26
TYPE 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. PALIA AVE., RIALTO, CA 92376 004566
Invoice
ADDRESS Ricielle thes
CITY, STATE,
CUSTOMER CADER NO. 190tD B TEOB
04/03/24)
ORDERED • SHIPPED PRICE Al-OUNT
199-05
16430k- 50
Estmade $360
(OTHER CEOMES) TO 400
= 684 20-15
)FIGUERUA 909-644-1274
025 California Code
LexIsNexIs ehicle Code - VEH
BuyCrash" 'IVISION 11 - RULES OF THE
OAD
HAPTER 4 - Right-of-Way
ection 21804.
Simply go to https://buycrash.com
information provide dol niversal Citation:
+ Veh Code § 21804 (2025) (?)
djunk and easy.
03/25/26 Next
Previous
O116
# 9326036240 804. (a) The driver of any vehicle about to ente •cross a highway from any public or private
fortunthe england please all the operty, or from an alley, shall yield the right-of- Lorder Boyd and copport lun 1 866-215-2771. ay to all traffic, as defined in Section 620, LoxisNexis ›proaching on the highway close enough to
institute an immediate hazard, and shall
intinue to yield the right-of-way to that traffic
SPICERA til he or she can proceed with reaso prip FeA
Contra
POLICE
Cameled To Our Coating
PICFRAI PICFRAI
PICERA C
PICFRAI