CITY OF RIALTO 2TA L TO CITY CLERK'S DATE STAMP
BAHO, CKAT CITY OF
LIABILITY 2025 APR 20 AH 8: 41
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY CLERK
CIT
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 nol later than one (1) year after the occurrence (Gov. Code 59112). 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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Riatto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
LINECIA JACKSON
- 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: 4/15/2026 - TIME: 1300 DAMOPM
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. 14 persena venicie was towed by Hopes Towing Service
did
after 1a to PD cole thair search Francisco Gi was the
owed the vehicle and took my belongings
3. HOW DID DAMAGE OR INJURY OCCUR?,
1 left all my belongs inside of my sebicle and When
- pered up my vehicle my necklace was missing
4. WERE POLICE AT THE SCENE? EYES D NO WERE PARAMEDICS AT THE SCENE? DYES ONO
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.
repés tow. seruice stole my necklace
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, efc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE: (stolen)
Item/Date: lok guld France necklace Amount: $1, 000
Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 1,00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hem/Date: Amount: S_
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
+ 900: 04
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:
NAME: NAME:
ADDRESS: _ ADDRESS:
TELEPHONE: L TELEPHONE: L 1
DATE: TIME: ДАМ 0IPM DATE: _
- 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 comers. f a cityftown 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 vehich men you hirst saw City/ own vehicle; location of City/Town vehicle al 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
* Fouthill
ivd Home Parking 10+
Deput
) I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
art cur JacksoN
4/20/2026
TYPE OR PRINT NAME DATE
sev
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 82376 4/16/26,5:13 FM Invoice
Pepe's Towing Service Impound Receipt
PO Box 7450, Moreno Valley CA 92552
Printed 4/16/2026
Phone: (951) 682-5682Fax Fax: (951) 682-5030
Towing Goraler
Released To RINECIA JACKSON Phone:
Invoice # 26-0415-79473 Reason for Impound 22651-H DRIVER ARRESTED Call # 79473 VIN Number
Case # 932604505 Model 2020 Mercedes-Benz GLE (White)
Case # 932604505 License Plate
Account RIALTO PD Drivable No
Date/Time Requested 4/15/2026 12:23 PM Keys Yes LOCK BOX 64 Date/Time Dispatched 4/15/2026 12:24 PM Towed from N Cedar Ave & Historic Rte 66, Rialto, CA 92376, USA Date/Time Arrived to scene 4/15/2026 12:29 PM Stored at Rialto Yard Date/Time Towing Time: 4/15/2026 12:38 PM 2775 N Locust, Rialto CA 92377 Date/Time Completed: 4/15/2026 12:55 PM
Driver Francisco G.
Truck TRK 39
Date/Time Released: 4/16/20265:08 PM APR 20 CITY OF
Days Held in Impound 2 days
Notes
Storage charges Quantity Price coLine Total
(Storage - Storage Fees) Impounds/Storage: Daily Impound Rate 2 $77.00 F$154.00 (Storage) After Hour Release Fee 1 $192.50 -$192.50
Towing charges Quantity Price Line Total
(Towing) TOWING FEE PORT TO PORT (price per hour) 1(sh) $385.00 $385.00 (Towing) Admin Fee $121.00 $121.00
Towing SubTotal $506.00
Storage SubTotal $192.50-
Storage - Storage Fees SubTotal $154.00
Subtotal $852.50
Taxes $0.00
Grand Total $852.50
Amount Due: $0.00 / Paid
MasterCard payment (Ref # CC 9676 APV 788947) of $852.50 applied on 4/16/2026 All towing services sales are final at time of payment By authorizing payment, you agree to the following terms:
No Cancellations/Changes: Once service is dispatched or rendered, payments cannot be canceled or modified No Refunds: All fees (towing, recovery, storage, etc.) are non-refundable.
No Chargebacks: Disputing valid charges may lead to additional fees.
By proceeding with payment, you confirm acceptance of these terms.
Pepe's Towing Service appreciates your business; if you have any questions regarding this invoice, please contact us at 951-682-5682. Thank you.
I Have been advised that my vehicle may be damaged if winched, towed, unlocked, jump started, tire changed or left on unattended premises. I recognize the difficulty involved and I agree not to hold Pepe's Towing Service responsible for such damages should it result. I, the undersigned do hereby certify that I am legally authorized and entitled to take possession of the vehicle described and all personal property therein. I have received the vehicle and all personal property in satisfactory condition.
Signature: Date:
CA# 117433 USDOT: 1005094
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice https:/iapp.towbook.com/impounds/Impound?id=27773688#Payment 1/1
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
NOTE CHP 180 IS FURNISHED TO ALL PEACE
VEHICLE REPORT STORED OFFICERS BY THE CALIFORNIA HIGHWAY PATROL CHP 180 (Rev. 4-16) OP| 061
REPORTING DEPARTMENT LOCATION CODE DATE / TIME OF REPORT NOTICE OF STORED VEHICLE FILE NO.
DELIVERED PERSONALLY
RIALTO POLICE DEPARTMENT 3609 4-15-26 / 1300 932604505
LOCATION TOWED / STOLEN FROM ODOMETER READING VIN CLEAR IN SVS? X YES NO DATE / TIME DISPATCH NOTIFIED LOG NO 1451 W FOOTHILL BLVD N/A LIC CLEAR IN SVS? IX YES 4-15-26 / 1222 YEAR MAKE MODEL BODY TYPE COLOR LICENSE NO. ONE MONTH/ YEAR STATE 2020 MERCEDES GLE 350 SUV WHITE X; Two 05/26 CA
VEHICLE IDENTIFICATION NO ENGINE NO. VALUATION BY ¡ OFFICER X OWNER N/A _ 0-500 L 501-4000 4001+ x) $ 18000
REGISTERED OWNER • SAME AS RIO LEGAL OWNER
RINECA JACKSON SCHOOLS FIRST FCU
POBOX 11547
SANTA ANA 92711
STORED - IMPOUNDED [_ RELEASED • RECOVERED - VEHICLE / COMPONENT
TOWING / STORAGE CONCERN (NAME ADDRESS PHONE) STORAGE AUTHORITY AREASON PEPES TOWING 909 574 1490 CVC 22651(H)(1)
REASON FOR STOP AIRBAG? DRIVEABLE? VIN SWICHED?
INVESTIGATION X YES NO X YES
•1 • 2 NO I JUNK UNK YES X NO
CONDITION YES NO ITEMS YES NO ITEMS YES NO ITEMS YES NO TIRES / WHEELS
CONDITION
WRECKED SEAT (FRONT) X REGISTRATION X CAMPER X LEFT FRONT FAIR BURNED HULK per 431(c) CVC X SEAT (REAR) ALT. / GENERATOR X VESSEL AS LOAD X RIGHT FRONT -FAIR -
VANDALIZED X RADIO BATTERY FIREARMS X LEFT REAR FAIR C
ENG / TRANS STRIP TAPE DECK X DIFFERENTIAL OTHER X RIGHT REAR FAIR
MISC PARTS STRIP X TAPES X TRANSMISSION SPARE UNK
BODY METAL STRIP X OTHER RADIO X AUTOMATIC HUB CAPS NO
SURGICAL STRIP per 431(b) CVC X IGNITION KEY X MANUAL X SPECIAL WHEELS NO RELEASE VEHICLE TO RIO OR AGENT AGENCY HOLD 22850 3 CVC GARAGE PRINCIPAL / AGENT STORING VEHICLE (SIGNATURE) DATE / TIME FRANCISCO GUZMAN 04/15/26 1300
NAME OF PERSON AGENCY AUTHORIZING RELEASE LD. NO. DATE CERTIFICATION | THE UNDERSIGNED, DO HEREBY CERTIFY THAT I AM LEGALLY LT MORALE 01731 41626 AUTHORIZED AND ENTITLED TO TAKE POSSESSION OF THE ABOVE DESCRIBED VEHICLE
SIGNATURE OF PERSON AUTHORIZING RELEASE SIGNATURE OF/PERSON TAKING POSSESSION • STOLEN VEHICLE / COMPONENT EMBEZZLED VEHICLE X PLATE(S) REPORT
DATE / TIME OF OCCURRENCE DATE / TIME REPORTED NAME OF REPORTING PARTY (R/P) DRIVER LICENSE NO / STATE
LAST DRIVER OF VEHICLE DATE / TIME ADDRESS OF R/P TELEPHONE OF RIP | CERTIFY OR DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF SIGNATURE OF PERSON MAKING REPORT
THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
REMARKS
[LIST PROPERTY, TOOLS VEHICLE DAMAGE ARRESTS]
DRIVER'S NAME ARRESTED / SECTION? REPORTED BY CARGO / TYPE? VALUE S RENECIA JACKSON X YES No PC 245 CLJONES • YES X NO
BILL OF LADING ATTACHED
VEHICLE WAS CONTACTED IN REFERENCE TO A PC 245 INVESTIGATION. DRIVER WAS ARRESTED FOR THE OFFENCE. THE WINDOWS ON THE VEHICLE WERE ROLLED DOWN AND THE VEHICLE NOT PARKED CORRECTLY. DUE TO THE CHANCE OF THE VEHICLE BEING VANDALIZED OR STOLEN, IT WAS TOWED FOR SAFETY. VEHICLE WAS TOWED PER CVC 22651 (H)(1) DRIVER ARRESTED. PURSE, CELL PHONE AND OTHER MISC ITEMS WERE LEFT INSIDE THE VEHICLE.
FRONT LEFT SIDE RIGHT SIDE REAR
TOP
SIGNATURE OF OFFICER TAKING REPORT 1D NO SUPERVISOR REQUIRED NOTICES SENT TO REGISTERED CL JONES 01029 IDS
AND LEGAL OWNERS PER 22852