CITY CLERK'S DATE STAMP
CITY OF RIALTO CITY OF RIALTO
LIABILITY 2026 MAY 14 AMIO: 54
CALL SE CLAIM FOR DAMAGES
RECEIYCU
TO PERSON OR PROPERTY CITY CLERK
::
1. Claims for death, injury to person, orlo personal property must be filed not leter than six (6) months after the occurence (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 Mail: 150 S. Palm Ave., Rialto, CA 92376
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Address: 290 W. Rialto Ave., Rialto, CA 92376 CLAIMANT INFORMATION:
alvador Roque DATE OF BIRTH
FULL NAME
T HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
RINK WES BUSINESS TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM Rialto cit 9237t:
(if different from home address provided above):
3:20 PMAM 2PM
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 0/0-30 - 25 TIME:
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.
It started in the street my grass aud went to tur Back
fart of mystase
3. HOW DID DAMAGE OR INJURY OCCUR?,
Fice started in died grass intre street and Mored
to the loaf partof the Horse
4. WERE POLICE AT THE SCENE? EYES• NO WERE PARAMEDICS AT THE SCENE? AÎYES O 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. ANd APOOL- TOOLS AND MASTERAZE
ETODEGE TOOM
$12,000
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: M47671125
ESTONEGE rOOM ANd TOOLS - Amount: $
Item/Date: Amount: $ 7,000
ltem/Date: 700d TrailEre
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $17,000 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: • Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $14,000
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have informetion (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ) TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIE DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: [1
DATE: TIME: DAM 0 PM DATE:_
TIME: DAM IPM
9. 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" location of yourself or your vehicle when 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 the accident by "B-1" and the point of impact by "X".
+ NOTE: IF THE DIAGRARS BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
7 SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Salvador Doque 05-14-26
TYPE OR PRINT NAME
• DATE
MY STELE
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