# I was told by my guardin oficer to be Checked
at, to tave advantaged, do tee medica service
I am gettin? CITY OF RIALTO
now
LIABILITY haul a dab 2978 JUL 23
Inoume PL 3:39
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY te pay CITY CLEA
Pur this bill
1. Claims for death, injury to person, orto personal property must be filed not later than six (6) 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 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:
Jasmin Lopez Arauro (Higareda)
DATE OF BIRTH
FULL NAME
LV HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
N/ A
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
07.01. 2024 TIME: 12:20
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.
Injuries occurred at my home.
3. HOW DID DAMAGE OR INJURY OCCUR?,
Wos asulted by mu partner.
4. WERE POLICE AT THE SCENE? DYES/NO WERE PARAMEDICS AT THE SCENE? DYESNO JEWHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known. the detention unen 1 got taken into custodu
enter sent me to the delineo
medical assistences because 100 not haup medical
$. Insuranc
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 $323.00
101.2026 Amount: $.
Item/Date: i /A
N/A Amount: $_
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 333.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 0701.26 323.00
Amount: S
Item/Date: 07-01 26 Amount: $ 523.00
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 323.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (ettach additional pages, if necessary) NAME: N /A N/A
NAME:
ADDRESS: NIA NIA
ADDRESS:
A/A
TELEPHONE: L1 A A TELEPHONE: L 1 NA
8. IF INJURED, PROVIDE NAME, CONTACT INPORMATION AND DATE TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: _ Arraineac N/A
ADDRESS: P.O BOX 1588 ADDRESS: N /0
NIA
TELEPHONE: |877 247243 TELEPHONE: N/A
DATE: 07.01.266 IME: 12-201MDAM DATE: _ TIME: ДАМ • РМ
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 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 DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
7 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 /CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Vasmin Lepez Arujo 07•23-2026
TYPE OR PRINT NAME DATE
Sel
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 FACILITY: 34 SAN BERNARDINO COUNTY SHERIFF'S DEPARTMENT WEST VALLEY D.C - RECEIPT FOR CLOTHING
BOOKING NUMBER: INTAKE DATE: 07/02/2026 TIME: 0447
NAME (LAST, FIRST, MID): LOPEZ HIGAREDA, YASMIN ID: OFA TUB NUMBER: 2229
Article Color Description Article Color Description
DRESS TOP RED SHIRT
SKIRT PANTS BLUE PANTS
COAT SHOES BLK SHOES
UNDER W MULTI UNDERWEAR PURSE 2229
COMMENTS:
INTAKE OFFICER: A DEAN BOOKING OFFICER: A DEAN
RECEIVING OFFICER: A CUETO
INVENTORY OF CLOTHING WAS WITNESSED AND VERIFIED BY ME.
ARRESTEE SIGNATURE (X)
CLOTHING RETURNED
RECEIVED BY (X)
RELEASED BY (X) DATE:
I HEREBY AUTHORIZE THE RELEASE OF MY CLOTHING.
TO: RELATIONSHIP
INMATE SIGNATURE (X) DATE:
RECEIVED BY (X)
RELEASED BY (X) DATE:
-
ARROWHEAD RADIOLOGY MEDICAL
Amount Due:
$323.00
0 REQUEST FOR PAYMENT
Statement Summary
Billing Questions?
Account Name: ARAUJO YASMIN LOPEZ
Please Call:
Account Number: (877) 331-3729
Statement Date 07/15/2026 9:00AM-3:00PM PST MON-FRI
Due Date: Upon Receipt
Total Charges: $323.00
Total Insurance Payment: $0.00 Para asistencia en Espanol llame al numero arriba.
Total Insurance Adjustments: $0.00
Total Patient Payments: $0.00 Payment Options
Total Patient Adjustments: $0.00
Pay Online
Amount Due: $323.00 https://www.peryourhealth.com
ID: 4455*7131539.1
Access Key: R5FP8U
Visit Us Online Pay By Phone
To make a payment over the phone,
please call us at: (877) 247-2143
Visit us at: https://www.peryourhealth.com Enter Account Number: 4455*7131539.1 ZECCTOCZRA To update your insurance, address,
view accounD: 445713153 in ofice. Please detach and return the bottom portion. Pay By Mail Access Key: R5FP8U
of this statement with your payment.
NOTE: Please enter the website address exactly as displayed including https://
MAIL PROCESSING CENTER Account Number:
Dept OPI001
PO Box 600 Due Date: Upon Receipt
Oaks, PA 19456-0600
Do Not Remit Payment to this Address Amount Due: $323.00 Return Service Requested Amount Paid: $
i For help with billing questions, We accept credit card payments over the phone or online. please call: (877) 331-3729
Hours: 9:00AM-3:00PM PST MON-FRI
VISA
ADDRESSEE: MAKE CHECKS PAYABLE AND REMIT TO:
ARAUJO YASMIN LOPEZ ARROWHEAD RADIOLOGY MEDICAL
PO BOX 1888
GREENVILLE TX 75403
0002 000084
4455952948449800000000713153900100000323003
ARROWHEAD RADIOLOGY MEDICAL Page 2 of 6
Charges & Adjustments Payments Patient
Date Service Description (Qty) Provider Debits & Credits Balance Patient Name: ARAUJO YASMIN LOPEZ
Account Number:
Referring Physician: SCOTT A MEEKER MD
Site of Service: ARROWHEAD REG MED CTR ER
07/01/26 72100 LUMBOSACRAL SPINE LTD, 2 OR 3 $31.00
07/01/26 72125 CT CERVICAL SPINE WITHOUT CON $168.00
07/01/26 70450 CT HEAD WITHOUT CONTRAST $124.00
You Owe $323.00
-
A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.
Change of Address Primary Insurance Updates
Name (Last. First, Middle Initial) rimary Insured Nam
Primary Insurance Name Effective Date
Address
Primary Insurance Street Address
City State ziP
City State ZIP Telephone
Telephone Employer Name Group Number
Subscriber ID # Policyholder's Dale of Birth
Secondary Insurance Updates
Note: Secondary Insured Name
Secondary Insurance Name Effective Date
Please be aware that the above summary represents
Radiology services from your medical provider. You Secondary Insurance Street Address will receive a separate statement for services provided City State ZIP Telephone
by the hospital.
Employer Name Graup Number
Subscriber ID # Policyholder's Date of Birth