CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2025 JUN -5 PM 4:42
REDE
1. Clalms for death, injury to person, or 1o personal properly must be filed not later than i (6) months after the occumence (GoV! Code 5914. 2)5
2. Clalms for damages to real property must be fled not later than one (1) year after the occurence (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 Mall: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Maria G. Velasquez
+
DATE OF BIRTH
FULL NAME
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): Blormington, Ca 90314
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 60/3/26 TIME: 9:30 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.
On 4/3/20, Iwas transferred via ambulance fine pept/emt From tume to Kaiser Hospital Per paramedic Fire Dopt. voluntarily carried my pasonal bag §'cellphore" to ambulance. However, Inever did see my ceuphme
3. HOW DID DAMAGE OR INJURY OCCUR? near me or uponarniral. my iphore 17-promax was brown back to me at KaleRty Freng Completely broken, shattered screen Enable to fully inchon.
Per Firebest apologized for damaging mycelphre dreasswied me that
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? DESOnoTher Chiefwa ande ortresituation
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town were nice è caring to
$ |507.42
HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, Ilst doctor bills, repale estimates, etc. Please attach 2 estimates.
L.
DAMAGES INCURRED TO DATE:
iphone 17 Plumax 526Bs1lver Amount: $ 1507.42
Item/Date:
Item/Date: Amount: $
• TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1507.42 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 addltional pages, If necessary) NAME: ZACK Repept Om NAME: along benmes.
ADDRESS: _ Rialto pRepapt. ADDRESS: →
TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Laser formanente on. NAME:
ADDRESS: 176
ADDRESS:
JUVE
TELEPHONE: TELEPHONE: |). -5
DATE: TIME: • AM PM DATE: TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident clalms, 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 corners.
If a clty/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you fiest saw lt, and by "B" location of yourself or your vehicie when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself of 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.
CURB
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.
I CERTIFY IOR NECI AREI LINDER PENAI.TY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Mana 6 Velasquez 4/4/2024
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 Liability Claims - Filing a Claim
In the event an incident occurs, the affected person/group/business may file a claim with the City of Rialto. A claim against the City must be made in writing. A CLAIM FORM must be submitted to the City Clerk's Office within six (6) months of the date the incident occurred. If there is not enough space on the claim form, please use additional paper and identify information by paragraph number.
The claim form must be accurately completed, printed, signed and mailed or hand-delivered to the address below. Electronic and facsimile filings will not be accepted.
Submit claims in person; Submit claims by mail:
City of Rialto City of Rialto
City Clerk's Office Attry City Clerk's Office
290 W. Rialto Ave 150 S. Palm Ave
Rialto, CA 92376 Rialto, CA 92376
Allow approximately 45 days to process and investigate your claim and all information/documentation submitted **Please be advised a claim submitted does not guarantee a commitment to pay your claim or an admission of liability. All information submitted will be evaluated and investigated to make a final liability decision.** Contact Us
City Clerk / Management Services
Email Ciry Clerks Office
Phone: (909) 820-2519
2075 JUN -5 PM 4:42 CITY OF RIALTO
Apple Victoria Gardens
12461 S. Main Street
Rancho Cucamonga, CA 91739
[email protected]
909-803-5220
www.apple.com/retail/victoriagardens CITY CLLAK 2076 JUN -5 PM 4: 42 CITY OF RIALTO December 22, 2025 01:55 PM
iPhone 17 Pro Max 512GB Silver $ 1,399.00
Part Number: MFXK4LL/A
Serial Number: LWXG74M27G
IMEI: 356605224169603
Return Date: Jan. 08, 2026
For Support, Visit: www.apple.com/support
Use of iPhone constitutes acceptance of the iPhone terms and conditions and other third party terms and conditions found in the iPhone box, or at http://www.apple.com/legal/sla/.
If you are not fully satisfied with your iPhone purchase, you can return your undamaged iPhone within 17 days of purchase for a full refund with no restocking fee.
If you disagree with these terms and conditions you can return the iPhone in accordance with the Apple Store's return policy http://www.apple.com/legal/sales_policies/retail.html For information on Apple's privacy policy see www.apple.com/privacy Sub-Total $ 1,399.00
Tax $ 108.42
Total $ 1,507.42
Payment Method
Amount Paid Via Cash $ 1,200.00
Amount Paid Via US DEBIT (Chip) $ 307.42
761602
*20251222R0941126599*
Please debit my account •• 6348 by $ 307.42 (Sale)
Card Number: *•.. 6348
Date/Time: 2025/12/22 13:54:33
Application ID: A0000000980840
•
Application PAN Sequence Number: 00
Trace Number: 00997150
Device Id: 0042
Card Type: Debit 2- 2076 JUN -
TVR: 8000048000
TSI: 6800
Verified by PIN CITY OF RIALTO
P: 4:43
https://www.apple.com/legal/sales-support/sales-policies/retail_us.html Apple can recycle your old electronics, visit apple.com/recycle to learn how Learn how to set up your product and transfer your data from home at support.apple.com.
CITY OF SALTO
A KAISER PERMANENTE.
AFTER VISIT SUMMARY
Maria G. Velasquez • 6/3/2026 Q FMC FMED EMG 888-750-0036 Instructions
HOME HEALTH
Your doctor has ordered visits from our home health for PHYSICAL THERAPY for evaluation/treatment and for home safety evaluation; they will contact you and arrange to come to your home after your discharge from the hospital.
FONTANA HOME HEALTH
If you need to contact someone in regards to this, please call the Kaiser Permanente Fontana Home Health Department:
Office Hours 8:30am - 5:30pm - (909) 609-3800. After Hours - (888) 576-6225 (888-KP-ONCALL).
Your medications have changed today 2025 JUN - 5 CITY OF See your updated medication list for details.
Read the attached information ERa RIALTO
ORTHOSTATIC HYPOTENSION (ENGLISH) : 4: 43
Pick up these medications at KP FO FONTANA 24 HR
Albuterol
Address: 9961 Sierra Ave, Hosp Bldg, Fl 1, Fontana CA 92335 Phone: 855-434-2155
Referrals made today
REFERRAL PHYSICAL THERAPY / OCCUPATIONAL THERAPY
Where: *FONTANA
Address: FOR REFERRALS ONLY FONTANA CA 92335-6720
Expires: 6/3/2027 (requested)
REFERRAL HOME HEALTH CARE
Where: *FONTANA
Address: FOR REFERRALS ONLY FONTANA CA 92335-6720
Expires: 6/3/2027 (requested)
Follow up with ALEX ZUCKER MCDONALD MD, M.D.
Why: As needed, If symptoms worsen
pecialty: Family Practice
Contact: 9961 SIERRA AVE
Fontana CA 92335-6720
833-574-2273
Maria G. Velasquez (MRN: 000014212911) • Printed at 6/3/2026 1:41 PM Page 1 of 8 Epic This is confidential information. Do not throw away in a Kaiser Permanente trash can.
Today's Visit
You were seen by AURORE RICHARD DO
Diagnoses
• POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME
• ORTHOSTATIC HYPOTENSION (LOW BLOOD PRESSURE UPRIGHT)
• CHRONIC FATIGUE SYNDROME
• SHORTNESS OF BREATH
W Lab Tests Completed
BLOOD UREA NITROGEN (BUN)
CBC (COMPLETE BLOOD COUNT) WITH DIFFERENTIAL
CREATININE
CITY 0* R::
ELECTROLYTE PANEL
Situ.i
GLUCOSE
N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE
TROPONIN I 01.
URINALYSIS
URINALYSIS
WHITE BLOOD CELL DIFFERENTIAL
# Imaging Tests
X-RAY CHEST
* Done Today
INPATIENT DISCHARGE PLANNING CONSULT
& Medications Given
Albuterol (PROVENTIL) Last given at 12:07 PM
sodium chloride 0.9% Stopped at 12:00 PM
Blood Pressure Temperature Pulse § Respiration
O 132/97 $ 98.6 °F 10) 94 25 16
Oxygen Saturation
98%
What's Next
Office Visit with MONIKA UPADHYE CURLIN MD DERMATOLOGY
Tuesday August 182:15 PM 9961 SIERRA AVE
FONTANA CA 92335-6720
833-574-2273
Maria G. Velasquez (MRN: 000014212911) • Printed at 6/3/2026 1:41 PM Page 2 of 8 Epic This is confidential information. Do not throw away in a Kaiser Permanente trash can.