CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF AALTO
CLAIM FOR DAMAGES
2025 MAY -4 AM 9:01
TO PERSON OR PROPERTY
KLCEIVEL
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months afer the occurrence (Gov. Code 59112) IT Y CLERM
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:
PeRez Angelica
FULL NAME - DATE OF BIRTH
(..
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INGLUDING 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 OCGUR DATE: MON., MARCH 30, 201 4RME: 09:00
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
UN SIDEWAK, ON CEDAR AVE, EAST SIDE OF CEDAR AVE BETWEEN I RANDALL AVE AND IN MERILL AVE.
3. HOW DID DAMAGE OR INJURY OCCUR?
WAKING ON SIDEWALK PAVEMENT. I WAS WALKING ON THE
SiDEWAIK, I tRiPPED ON A SigNiFICANTLY UNEVEN SECTION OF PAVEMENT. SUFFERED AN INJURY ON RIGHT KNEE.
4. WERE POLICE AT THE SCENE? •YESTÁNO WERE PARAMEDICS AT THE SCENE? •YESENO
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.
FAiLURE TO MAINTAIN THE SIDEWALK ON AMAN STREET IN A SAFE CONDITION, SPECiFiCALLY THE PRESENCE DF A SiGNiFiCANTLY BUSY STREET AND UNEVEN SECTION OF PAVEMENT. IT'S. HAZARDOUS+ DANGEROUS. $$1440.00
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:
Hem/Date: LOss of WAGES DUETO INJURy TUES. 3/31/2026 360.00 Amount: $
Item/Date: Loss of WAhks DuE TO INury+ Amount: $ 3l0.00 4|1/2026
itEM DAELOsS of WARES DuE TO INJury H H360.00
iTEM/DATE: luSS of WAnts DuE 10 INjury 41312026 4360,00 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: = 1440.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY OF RIALTO Item/Date: NA Amount: $
2020 KAY A: 9:01
Item/Date: NA Amount: $
$
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES CLEA
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary)
ARCELA PEREZ ADOLFO PENEL
NAME: NAME:
ADDRESS:
TELEPHONE: TELEPHONE: (
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NA
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: |)
TIME: • AM • PM DATE: TIME: • AM • PM
DATE:
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.
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" location of yourself or your vehicle when 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 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.
CEDAR AVE
AVE (WEST <jOr)
Minos ANDALL MERiLL
CEDAR AVE SiDE)
EAST
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TI HOSE 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
VAndelica PeRez 4/220/2026
TYPE OR PRINT NAME DATE
IEL+
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 rEKEL, HAGILO page 1 oF 8
CITY
2028 MAY
NORTH
Ave
(EDAR
DRTH
NORHH
LEORE ANE
(EnS:
PEREZ, Angelica page 2 oF 8
HILTON
EAST SIDE CEDAR AVE
1 KON CEDAR AVE (ER
CITY CLERA RECEIVLU 2026 MAY -4 AM 9:01 CITY OF RIALTO
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CEDAR AVE (ENT)
PEREZ, Angelica page sur o
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PEREZ, Angelica page 4 of 8
Right Knee/leg
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2028 MAY -4 AN S: 01
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PEREZ, ANGELICA
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CITY CLERK
RECEIVEL
2026 MAY - 4 AM 9: 02
CITY OF RIALTO
HEREZ, ANGELICA page 7 of g
Right Knee leg CITY CITY OF
PAGE 9 OF 8
PEREZ, ANGELiCA
CITY OF RIALTO
2026 MAY -4
RiALTO, CA 92376
150 S. PALM AVE.
RiALTO CiTY CLERK'S OFFiCE
CiTY 7026 MAY -4 CITY OF RIALTO
A 9: 0E
PEREZ. ANGELiCA