CITY CLERK'S DATE STAMP
CITY OF RIALTO CITY OF RIALTO
LIABILITY 2026 AUG 26 AM 9:20
CLAIM FOR DAMAGES RECEIVED
TO PERSON OR PROPERTY CITY CLERK
1. Claims for death, injury to person, orto personal property must be filed not later than six (6) months affer the occurence 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., Rillo, CA 92376
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Address: 290 W. Rialto Ave., Rialto, CA 92376 CLAIMANT INFORMATION:
Lesse Metoza DATE OF BIRTH
FULL NAME
HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
FE
RIALTO CAL. 92377
SEEK TELEPHONENO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
WiFE
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
8-21-26 TIME: 5:00
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. 92377 116 DALE Wood AV E RIALT O
3. HOW DID DAMAGE OR INJURY OCCUR?, in costudu
DONT Know 1 was
over PHONe wallet. cause
t ran
ATM doc it work so/ Had to order one
4. WERE POLICE AT THE SCENE? EYES NO WERE PARAMEDICS AT THE SCENE? EYES ONO
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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $15150° HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Amount: $.
Item/Date:
Amount: $.
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $1500 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hter/Date: I PHoNe 7 Amount: $71,500
Hem/Date: HAd to ORDER ATM Amount: $1$1500
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $1,515%0
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: 1
DATE: TIME: 0 AM OPM DATE: _
TIME: DAM PM
8. 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 vehick 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
7 SIDEWALK
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 I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMAN OR AGENT
Jesse RayGozA 8-26-26°
TYPE OR PRINT NAME • DATE
Owner of PHoNe ¿ ATM
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150S. PALM AVE., RIALTO, CA 92376 Customer Assist How Do I... Logi
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ENGLISH V
PREMIER DEBIT CARD (..8931)
Reason
Card wasn't received
JESSE RAYGOZA (sole owner)
Shipping address
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Estimated delivery Aug 27 - Aug 28
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