CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
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 RECEIVED after the occurrence. (Gov. Code Sec.911.2)
3 Read entire claim before filing
See page 2 for diagram upon which to locate place of accident FEB 1 4 2023 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. CITY CLERK'S OFFICE
7. Claim must be filed with City Clerk. (Gov. Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
Keith Carrillo 42
Home Address of Claimant City and State Home Telephone Number 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.
Pothole in the number one lane closest to the median. I hit the pothole driving approx. 35-40 mph. I could not avoid it as there was traffic in the right lane. It caused catastrophic tire failure causing it to explode and bending/warping my left front rim.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
01/17/23 @ 1823 (night)
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
4984-5098 Bandini Blvd in the Number 1 lane. West of 710N off Atlantic What particular ACT or OMISSION do you claim causedthe injury or damage? Give names of City employees, if any, causing the injury or damage, if known:
Did not repair the road in an adequate time frame. Multiple potholes on that road, which is driven by large trucks.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Bent/warped rim and tire damage. I recently bought brand new tires in September 22. I have a staggered wheel set with the front 225/40r18 and the rear 255/35r18. I have included both receipts of purchase in 2022 and the single tire I bought the day after the event occurred. I also had to buy an aftermarket rim, as the OEM rim was an exuberant amount and believe the equivalent is acceptable. (all receipts/map included) What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
Rim: $210.07 + Tire: $91.33 = Total: $310.40
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
Rim: $210.07 + Tire $91.33 Total $310.40
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Yes, I did not file a claim, as my deductible is $500
Statefarm, Policyl
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Rim: $210.07 + Tire $91.33 Total $310.40 $310.40
Name and address of Witnesses, Doctors and Hospitals:
N/A
READCAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident bv "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
7AT7
FOR OTHER ACCIDENTS
wite //// F/ LANE
SIDEWALK
CurB/
CURB;
PARKWAY
SIDEWALK
EAST
B.U.
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 Date:
relationship laimant:
Keith Carrillo 01/31/23
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION 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 Claim for Damages
To whom it may concern:
I am writing this regarding my claim for damages. I was coming home from work in the city of Los Angeles. I use Bandini blvd to go home. It had just rained the previous week. I was traveling East bound on Bandini towards the 710 fwy (view attached map for location/address) There was a pothole in the number 1 lane which was unavoidable. It was already dark out and I was traveling approx. 35-40 and tried to brake to slow down but it was to late. I could not perform any invasive maneuvers as there was a car in the lane to my right. Hitting the pothole caused my tire to explode. I purchased a new tire and when I went to the tire shop to mount the tire they informed me that my rim was bent. I had to purchase an aftermarket rim which was a cheaper option. I believe a rim is a rim and serves one purpose which is to hold a tire that is balanced. I did not opt for an OEM rim which was around 1000 dollars. It looks and performs the same. I am asking that this claim be reimbursed for damages done by the road in the amount listed on the claim form. Thank you for any and all consideration into this matter.
Carrillo
8:081 • 5GE• 8:07 4 •ll 5G E 0
De Well Group ©
US Army
Reserve Center
Done
BANDINI BLVD Hapi Products C
IST'S
E Lineage O
Logistics
2D
. E'
Classic Ho
Headquar
AYERS AVE
Bakery Depot O © Ameri
Tire D
Harvest Meat Co O © Randall Foods
CLAR
BANDINI BLVD AYERS/AVE
88 45°
AQI 69 •
4984-5098 Bandini Blvd
Q Search Maps
Bandini, Vernon
Santa Ana Wheel
2607942
10 Nor B
Pose: (738036-1122 Fee Tell Free: Free:(877)724-9433 1232023 Petal
mone B Pinchee Order Pe Sales Reper Ship Dese Ship Via
Due on receipt Scot 123/2023 WILL CALL
Quandty hem Code Description Grade Price Each Amourt i
SILVER 74292 2017 Less IS350 18* 10 spcki rep sil 194.98 194.961 ray front wheel - replici
There will he a $25.00 Service Cha ee for ans returned Chocks Sales Tax (7.75%) $15.11
By signing this agreement entative agree to all sores and conditions and Invoice Total $210.07 tams after 30 deys shoes porchase 52300 fee for check has do not clea mal property has feen leth with Santa Ana i heet, and to dep out has bees mali she cana
ad he been a Da
- See levoices act paid within specifiel pay - Are waN
CA Customen
Warning: Cancer and Reproductive Harm
www.PrsW'amings.ca.gov
'..
10:39
• online.citi.com
Jan 25, 2023 Pending
ASHLEY CARRILLO
+ American Wheel & Tire BEL... $15.60
Jan 25, 2023 Pending
KEITH E CARRILLO
Posted Total ? $324.45
+ CHEVRON 0381778 MONT... $14.96
Jan 24, 2023
KEITH E CARRILLO
- IN *SANTA ANA WHEEL ... $210.07
Jan 23, 2023
ASHLEY CARRILLO
Purchased On
Jan 23, 2023
Posted On
Jan 24, 2023
Spend Category
Auto Parts, Accessories Store
Merchant Country
United States
I want to..))
11:29 • | 5GE C
4 Search
Order details
Your item was delivered.
Delivered on Thu, Jan 19
Track package.
times
Vime placed Jan 17, 2023 at 7:11 PM resent
Order number 12-09595-18767
$91.33 (1 item)
Sold by get_some_tires
Delivery info
Delivered on Thu, Jan 19
Paid Shipped Delivered
Jan 17 Jan 18 Jan 19
Item info
1X Ohtsu FP7000 225/40R18XL 92W
BW Tires
Fits your 2014 Lexus IS350
$81.81
Returns accepted through Mar 20, 2023.
Leave feedback More actions...
Trackina details
A Q
Home My eBay Search Notifications Selling
10:40
@ online.citi.com
Jan 18, 2023
KEITH E CARRILLO
+ ELECTRONIC PAYMENT-T... -$365.00
Jan 18, 2023
KEITH E CARRILLO
- eBay 0*12-09595-18767... $91.33
Jan 18, 2023
KEITH E CARRILLO
Purchased On
Jan 17, 2023 10:11 PM ET
Posted On
Jan 18, 2023
Purchase Method
Online
Spend Category
Department Store
Merchant Details
Ebay
United States
Website
I want to...
11:31
• | 5GE 4
1 Search
Order details
Time placed Prevaus
Sep 8, 2022 at 11:25 AM
Order number 04-09079-64541
Total $208.38 (1 item) tire purciAnse
Sold by astlanetires
Delivery info
Delivered on Fri, Sep 16, 2022
Paid Shipped Delivered
Sep 8 Sep 9 Sep 16
Item info
2 New 225/40R18 Ohtsu (by Falken)
FP7000 Tires 225 40 18 2254018
$175.00
Return window closed on Oct 15, 2022.
Buy again More actions....
Tracking details
Number = 277774736280
Shipping address
Keith Carrillo
A Q
Home My eBay Search Notifications Selling