CITY OF RIALTO
SHALTO CLEA LIABILITY PARS JUN 23
CLAIM FOR DAMAGES hEvE PillA: 35
TO PERSON OR PROPERTY CITY CLE
. 1. Claims for death, injury to person, orlo personal property must be filed not fater 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:
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:
David Gonzalez
DATE OF BIRTH
FULL NAME
IN MUSL
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):
6-14-26 TIME: 11:58 DAM DP
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: -
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 tie fireway on Riverside Ave ending the camp
to merge
3. HOW DID DAMAGE OR INJURY OCCUR?,
Fus entering the freen dex at Tonging down
in the middle of the road, black hard side facing me the ramp.
4. WERE POLICE AT THE SCENE? DYES E/ NO WERE PARAMEDICS ATTHE SCENE? DYES •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.
city of Rialto
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2, 231.52 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
6-14-26 Amount: $.
Item/Date:
6-14-21 Amount: $_
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 6-4-24
Amount: $
Item/Date: 6-14-26 Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: = 2,231.52
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NA NAME:
ADDRESS:, ADDRESS:
TELEPHONE: ( TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NIA NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: L
DATE: TIME: DAM DIPM DATE:
TIME: 0AM OPM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident aims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST direclions. Indicate place of accident by "X and by showing house numbers or distances to street corners.
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.
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 TI HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE -CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
avid Gonzalez 6-23-26
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 Islas Auto Body Estimate ID
300 S Sycamore Ave Building B, Rialto, CA 92376-6579 28359134 Office: (951) 904-0479 Original
AUTO BODY [email protected]
islasautobody.com
2008 JUN 23
Owner Appraiser CITY CLER RECEIVE.
DAVID GONZALEZ Julio Islas CITY OF RIALTO
[email protected]
Classification PM12: 38
None
Loss Type Deductible
Unknown Unknown
2007 Acura TL Type S 4 Door Sedan 3.5L 6 Cyl Gas Injected 5 Speed Auto Trans FWD VIN Drivable Mitchell Service Code
Unknown 910258
Options
Air Conditioning Alum/Alloy Wheels AM-FM Stereo Anti-Lock Brake Sys. (ABS) Auto Air Condition Automatic Headlights Bluetooth Wireless Cassette Player CD Player CD Player (Multi) Connectivity
Cruise Control Daytime Running Lights Driver Seat With Power Driver-Front Air Bag Dual A/C Lumbar Support
Electric Defogger Electronic Stability Control Exterior Memory Mirrors First Row Bucket Seat Fog Lights Front Heated Seats Heated Mirror High Intensity Discharge Interior Automatic Keyless Entry System Headlights Day/Night Or
Electrochromatic Mirro
Leather Seats Leather Steering Wheel Left-Curtain Air Bag Manual Sunroc MP3 Player Navigation Sys. Passenger-Front Air Bag Power Door Locks Power Driver Seat Power Passenger Seat Power Remote Mirror Power Steering Power Windows Rearview Camera Remote Decklid Or Tailgate Release
Satellite Radio Side Airbags Steering Wheel Mounted Telematic Systems Theft Deterrent Sys.
Audio Control
Tilt Steering Wheel Tire Pressure Monitoring Traction Control/Electronic Universal Garage Door System Opener
DAVID GONZALEZ | 2007 Acura TL Type S
Parts Profile
AM and QR Parts
Parts Profile Version
2.0 LABOR PART
Line# Description Operation Type Total Units CEG Type Number Qty Total Price Tax Front Bumper
1 002849 Frt Bumper Cover Remove Body 2.1# 1.8 New 04711-SEP- 1 $452.68 Yes / Replace AZOZZ
2 AUTO Frt Bumper Cover Refinish Refinish 4.0° C 2.4
Only
Committed on Version Mitchell Cloud Estimating™ Printed On Profile Page 1 of3 Mitchell Estimating 26.1 Copyright 1994-2026 Mitchell International, Inc 6/23/2026 System profile OEM JUN_26_V 11:36 AM Profile Version
All Rights Reserved 13.0
• s
LABOR - PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax 900501 Modified Refinish With
Full Clear Coat
4 002853 L Frt Bumper Grille Remove Body INC# 0.2 New 71107-SEP- 1 $59.40 Yes / Replace AZOZA
Front Lamps
5 003868 LFrt Fog Lamp Remove Body INC# 0.3 New 33951-SEP- 1 $491.37 Yes / Replace A01
Additional Costs & Materials
6 AUTO Paint/Materials Additional $315.00 Yes
Cost
AUTO Hazardous Waste Additional $5.00* Yes
Disposal Cost
Additional Operations
8 AUTO Clear Coat Additional Refinish 25* 0.0
Operation
933003 Tint Color Additional Refinish 0.5° 0.0
Operation
10 933017 Finish Sand And Buff Additional Refinish 1.5% 0.0 Operation » '
* Judgment Item C included in Clear Coat Calculation OLTY T included in Two Tone Calculation A Included in Clear Coat and Two Tone Calculation # Labor Note Applies rCEG R&R Time Used for this Labor Operation d Discontinued by Manufacturer 1 Verify the part number and price before ordering Estimate Totals
Labor Units Rate Sublet Add'l Amount Totals
Body Labor 2.1 $80.00 $168.00
Refinish Labor 8.5 $75.00 $637.50
Total Labor 10.6 $805.50
Taxable $805.50
Tax 0.0000% $0.00
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Labor Total $805.50
Parts Amount
Taxable Parts $1,003.45 $1,003.45
Parts Adjustments $0.00
Tax 7.7500% $77.77
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Parts Total $1,081.22
Costs Amount
Paint Materials $315.00 $315.00
Shop Materials $0.00 $0.00
Other Additional $5.00 $5.00
Costs
Paint Materials: Taxable $320.00
- Refinish Units: 7.0 units Tax 7.7500% $24.80
- Rate: $45.00 Non-Taxable $0.00
- Rate Max: 99.9 units Pre-Tax Discount 0.00% $0.00
- Additional Rate: $0.00 Costs Total $344.80
Gross Totals Amount
Committed On Version Mitchell Cloud Estimating™ Printed On Profile Page 2 of3 Mitchel! Estimating 26.1 Copyright 1994-2026 Mitchell International, Inc. 6/23/2026 System profile OEM JUN 26 V All Rights Reserved 11:36 AM Profile Version
13.0 Estimate Totals
Gross Total $2,231.52 $2,231.52
Taxable $2,128.95
Tax $102.57
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Gross Total $2,231.52
Adjustments Amount
Total Customer $0.00
Responsibility
Net Estimate Total $2,231.52
Disclaimer: For your protection California law requires the following statement to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Estimate Event Log
Job Created 6/18/2026 12:33 PM CITY CITY OF
Estimate Started 6/18/2026 12:34 PM
Estimate Printed 6/23/2026 11:36 AM 2028 JUN 23 PM 12: 38 Estimate Committed Estimate Not Committed
Estimate Retrieval ID 1010694232 RIALTO
Committed On Version Mitchell Cloud Estimating™ Printed On Profile Page 3 of 3 Mitchell Estimating 26.1 Copyright 1994-2026 Mitchell International, Inc. 6/23/2026 System profile OEM JUN 26 V 11:36 AM Profile Version
All Rights Reserved 13.0
CITY OF RIALTO
2026 JUN 23 PM 12: 38
GEIVED
CLERA