CITY CLERK'S DATE STAMP
CITY OF RIALTO CITY OF RIALTO
LIABILITY 1029 JUN 16 A:M: 29
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY CITY CLERA
. 1. Claims for death, injury to person, orlo personal property must be filed not later than six (6) months after the occurrence (Gov. Code 5911.2).
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: 150 S. Palm Ave., Riatto, CA 92376
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Address: 290 W. Ratto Ave., Rialto, CA 92376 CLAIMANT INFORMATION:
Hernandez
DATE OF BIRTH
FULL NAME
• rI
1 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):
1. WHEN DO DAMAGE OR INJURY OCCUR DATE CUne 9,2026 TME: 10:30 NAM DIAM
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. Ricato Midalle Scool, Rialto Ca.
Kialto Ave, in tront p
I was traveling westbound in right lane on Rialto Ave
3. HOW DID DAMAGE OR INJURY OCCUR?
while driving westbound infront of halto Middle sched Me curl My wife heard an deled stilke the windshield of our car a 2011 ford Fusion LP# 9KW630, aşwe hecuel the stricke from the right side we saw a city of Rite wander olekiting a weed eatex along the gruss edge in shoolpatry
4. WERE POLICE AT THE SCENE? DYES INO WERE PARAMEDICS AT THE SCENE? DYES LINO
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.
After stop check Alle windshield saw a small crack in theupper right area af windshield, a vock un propelled by the weed eater and struck the windshield,, returned to the schoo immediatly and spoke is a city Winder who steded Hund the worker operatiny the weed eater haul left ste fattin $ 607.30
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: 60730
June 9, 2026 Windshield 2017 Farl Fisiamount: 8.
Item/Date:
Amount: $.
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: = 607,20 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hem/Date: 201 Windshield For a Amount: $.
Item/Date: Ford Fusion -v brid 207,30
Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $. 6001 70
MME JUan Hernandez Lovena
ADDRESS: _ ADDRESS:
TELEPHONE: 1 TELEPHONE: _
8. IF INJURED, PROVIDE NAME, CONTACT INFORBATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: None ADDRESS: None
TELEPHONE: TELEPHONE: L)
DATE: TIME: DAM 0 PM DATE:
TIME: • AM OPM
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.
If a citytown 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.
S
1 W- Rialto Ave. • CURE
ar
M PARKWAY
SIDEWALK A&WorKer
N Ave.
Rialto Midde school
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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
yan Hernandez
TYPE OR PRINT NAME • DATE
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
CITY OF RIALTO
2026 JUN |6 H: 29
UTY CLERI
2028 JUN 16 AMI: 29
CITY OF RIALTO
422
Invoice Jun 9, 2026
Due: Jun 10, 2026
From Bill to
Right Way Autoglass Juan Hernandez
[email protected]
9095454223
Fontana, California
DESCRIPTION RATE, USD QTY AMOUNT, USD
Windshield Replacement with lifetime warranty $564.35 1.00 $564.35 2017 Ford Fusion Hybrid
Ca Taxes $42.95 1.00 $42.95
Payment Instruction subtotal: $607.30
Paypal email: (0%): incl. $0.00
"N/A" Total: $607.30
Bank Transfer: Balance Due: $607.30
"N/A"
"Cash wallet \ nPaid cash \n \nCash payment
Incash payment \n"
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Invoice no.: 422
Invoice Invoice date: Jun 8, 2026
Due: Jun 9, 2026 Aura Bines
From Bill to
Right Way Autoglass Jaun Hernandez
[email protected]
9095454223
Fontana, California
DESCRIPTION RATE, USD QTY AMOUNT, USD
Windshield Replacement with lifetime warranty $564.35 1.00 $564.35 2017 Ford Fusion Hybrid with Recalibration
Ca Taxes $42.95 1.00 $42.95
Payment Instruction Subtotal: $607.30
(0%): incl. $0.00
Napol email:
Total: $607.30
Nik Transfer: Balance Due: $607.30
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"Cash wallet \Paid cash \n \nCash payment
Incash payment (n
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