CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS RECEIVED
1. Claims for death, injury to person or to personal property must be filed not later than six (6) months after the occurrence. (Gov. Code Sec. 9112)
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2) JAN 1 2 2023
3. Read entire claim before filing
See page 2 for diagram upon which to locate place of accident CITY CLERK'S OFFICE
5. This claim form must be signed on page 2 at bottom.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
7. Claim must be filed with City Clerk. (Gov. Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (li natural person)
irene young 31
Home Address of Claimant City and State Homes telenhone Numher Business Address of Claimant City and State Business Telephone Number Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
Got a fiat tire due toa potholes near 4105 Bandini Biva, vernon, CA 9005s. Had to get car tourd and had to
replace entire rear tire (non-repairable)
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Thursday 1/5/2023 7am
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram onreverse side of this sheet, where approximate, give street names and address and measurements from landmarks Had to replace whew tike due to damage from the pothole.
There's a punoes back to back near west coast Rendering co. 4105 Bandini Bvd, verun, What particular ACTor OMISSION doyou claim causedthe injury or damage? Give names of City employees, if any. CA 90058. causing the injury or damage, if known:
Dring through the pothole caused my tire to be damaged
and nih-repairable
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
damage - fat tire; replacement of tire.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$271.11 for new tire
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation
$271.11 for new tire
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Expenditures made on account of accident or Injury: (Date - Item) (Amount) 1/5/2023 - 1 new tre $271.11
Name and address of Witnesses, Doctors and Hospitals:
READ CAREFULLY
-or all accident claims place on following diagram names of streets, including North, East. South, and West: indicate plac f accident by "X" and by showing house numbers or distances to street corners NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
7AMT
potholes near 4i0s
FOR OTHER ACCIDENTS Bandini Bivd
indiana 4105 Bardini vernon, 0A 90658
Bird, repos o Beach
SIDEWALK
CURB!
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving relationship to Claimant:
Irene Young • en 1/11/2023
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. RESENTATIO OF A FALSE CLAIM IS A FELONY (CAL PEN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV.CODE SEC.915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) Rev. 8/4/16
west coast kendering co
Sindiana St
Sindiana St
Bandini Bivd
Sindiana St
Bandini Bivd
Bandini Bivd
Bandini, Bivd
Google Bandini Bivd
02023 CNES/ Arbus. Maar Technologies, US Geological Survey, Map asts 42021 Approximate location of
potholes
Nest Coast Rendering Co - rene yong
.5 **** 13 reviews
issociation or organization
Drections Save Nearb; Send lo Share
phone
4105 Bandini Bivd. Vernon, CA 90058
(323) 261-4176
2R35+P4 Vernon, California
Send to your phone
Claim this business
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COSTCO
-WHOLESALE
TUSTIN #1001
2700 PARK AVE
TUSTIN, CA 92782
21100109500292301051943
Member 111882328921
1549231 235/40R19 P 249.99 A
9999999 Ring/Linked 1.75
SUBTOTAL 251.74
TAX 19.37
**** TOTAL 271.11
XXXXXXXXXXXXX199 CHIP read
APPROVED - PURCHASE
AMOUNT:$271.11
01/05/2023 07:43 1001 95 29 158
VISA 271.11
CHANGE 0.00
(A) A 19.37
TOTAL TAX 19.37
TOTAL NUMBER OF ITEMS SOLD = 1
01/05/2023 07:43 1001 95 29 158
Thank You!
Please Come Again
Whse: 1001 Trm: 95 Trn: 29 OPT: 158
Items Sold: 1
P7 01/05/2023 07:43
Receipt for new tire
- lene young
picture of
flat
tire
from
1/5/2023.
- veneyung
Calmeage.
picture of
potholes.
1/11/2023.
they we
filed a
notice to
- Mine reng
- pothole
patched up
1/1V/2023.
Check
records
shard be
Able to
see how
- Irene yang
picture
taken on
V/11/2023.
incidentor
pothole
was
1/5/2023
you rovid
sel from
asphalt
that it
was just
patched
Drove by att
7am on
V/IV2023,
pot hole was
Still there. I
reportea it at
7:30am 1/11/2023
when i went back
0h 1/11/2023 10:200r
it ovas pathed up.
- Irene yure