CITY CLERK'S DATE STAMF
CITY OF RIALTO CITY OF RIALTO
LIABILITY 207G MAY 28
Ph 5:50
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY LITY
CLERA
1.Claims for death, injury to person, or to personal property must be filed not later than six (f) months after the occurrence (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
4.ATTÁCH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Jacobo Bendanin Paredes Galindo
NATE AF RIRTH
FULL NAME
HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
nice/to 97 376
• n BUOINESS 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):
5-15-2026 9:30 CAM PM
TIME:
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE:
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) focate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
Mobile Home Park entrant officeR Kept saying
that I was drunk, was natany trying to ENtimidate
He placed
sureen broke.
4. WERE POLICE AT THE SCENE? DYES ONO WERE PARAMEDICS AT THE SCENE? DYESONO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee pausing the injury or damage, if known. male wanted to officer.
call my boss
have been zerosing to give me helf.
6. GIVE TOTAL AMOUNT OF CLAIM include estimate of amount of any prospective injury or damage $1650. 3200 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO RATE: | 600
IPHONE 11 Amount: $.
Item/Date: 1600
IPHONE 14 Amount: $.
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: • 16:000 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/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: ME. The neighbors
NAME:
ADDRESS: DONT KNOU ADDRESS:
THEM
TELEPHONE: L TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATETIME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: d TELEPHONE: L 1
DATE: TIME: ПАМО РМ 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 of distances to street comers.
If a cityitown 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.
PARKWAY
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.
VEERTIFY IOR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Jacobo 5-28-2026
TYPE OR PRINT NAME DATE
Myself
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