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. FEB 21 2023
4. See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom.
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)
MICHAEL GALLANT WEST COVINA CaNINa, CA
Home Address of Claimant 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.
DROVE OVER POTHOLE OFFRAMP OF ATLANTIC/BADINI
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
JAN 2023 7:45pm
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:
OFFRAMP OF ATLANTIC/BANDIN- SOUTHBOUND
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:
POTHOLE CAUSED DAMAGES TO ALL FOUR RIMS ADD
TIRES
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
ALL FOUR RIMS OF CAR SEVERELY PAMAGED+ PUNCTURED TIRE
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
2109.46
Give ESTIMATED AMOUNT as faras knownyou claim on account of each item of prospective injury ordamage, giving basis of computation
2109.46
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. AAA
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
READ CAREFULLY
For all accident claims place on following diagram names of streets, including North, tast. South, and West: indicate plac of accident by "X" and by showing house numbers or distances to street comers vehicle at the time of accident by "8 1" and the point of Impact by "X." NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS - SZE BACK
OF PAGE
7^1
FOR OTHER ACCIDENTS
CURB:
CURB ;
PARKWAY
SIDEWALK
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:
Mihad Dallant relationship to Claimant: 1214/23
tallan
MICHAEL GALLANT
710 SOUTHBOUND OFFRAMP@ ATLANTI/BANDINI
NOV 10
- VOOMOBI
- LOCATION OF POTHOLE
LOK O.HEB VOCID
0910 g
TOYOTA
Envision Toyota of West Covina
1800 East Garvey Avenue
Meet Coving, CA. 91701
(626) 859-7400
Parts and Service Hours: Monday - Friday /:00am - 6:00pm Saturday 7:00am - 5:00pm. Sunday Closed
Refunds over $50 dollars will be paid by checks. Check will he issued within 14 dave of return. Parte not returnable after 10 days. 20% restocking fee on all returned parts Electrical and Special order parts are not returnable. No refunds without this invoice. Refer to reverse side for limited warranty. Remanufactured parts will be noted in the description field of an X suffix Non OEM parts may be used. Please see your dealer representative to help determine the part manufacturer
DATE ENTERED YOUR ORDER NO. DATE SHIPPED INVOICE DATE INVOICE 14 FEB 23 14 FEB 23 NUMBER Q187400 16:02
**QUOTE**
§ ACCOUNT NOE50 PAGE 1 OF 1
CASH - RETAIL P
SHIP VIA REP. 3/L NO. TTERMS IF.O.B. POINT
4123 CASH - RETAIL WEST COVINA, CA
PART NO. DESCRIPTION LIST NET AMOUNT
42611-52503 WHEEL, 120.14 120.14 480.56
42602-52320 CAP SUB 127.10 127.10 508.40
DT001-32803 -YK OEA 195 148.05 148.05 592.20
0 90080-45006 VALVE 26. 96| 26.96 107.84
**** INVOICE QUOTE - DO NOT PAY ****
#180.00
Alaunche $ 10.95
$0109.414
PARTS HOT LINE (760) 745-9925
PARTS FAX LINE (442) 286-7522 PARTS 1,689.00
WE TRULY APPRECIATE YOUR BUSINESS! SUBLET
FREIGHT 0.00
SALES TAX 160.46
CLIENT'S SIGNATURE
X TOTAL $1,849.46
TERMS
2/15/23, 10:50 PM Photo - Google Photos