CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
•TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
1..• than six (6) months after the occurrence. (Gov. Code Sec.9112) Claims for death, injury to person or to personal property must be filed not later
RECEIVED
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing. FEB 2 7 2023
See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom.
CITY CLERK'S OFFICE
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 24
Name of Claimant Age of Claimant (If natural person
Alexandra Alvarado
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant Cify and State Business Telephone Number Give address to which you desire notices or communications to be sent regarding this claim:
I was arving on washing ton bird where there were many potholes and low did DAMAGE or NJURY occur? Give full partic
occured on 1/1/23 at 6:40 am
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
S Grande vista & washington, City of Vernon
Where did DAMAGE or INJURY occur? Describefully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
There were many potholes in that street
What particular ACT or OMISSION do you claim causedthe injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
Caused damaged to mu front right side tire which also caused damaged to my rim What DAMAGE or INJURIES do you Claim resulted? Give full extent of injuries or damages claimed:
Total Tires Rim
$ 1,032.92; $ 240x2 & $552.92)
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
$240x2) had to replace tire twice due to rim damage, rim is $55292 you claim on account of each item of prospective injury or damage, giving To mumount: 1,032.12
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received: claim #
progressive insurance policy #
Expenditures made on account of accident or Injury: (Date - Item) (Amount) 2240 tire 1/"23; $240 tire 1/23123; (Pending Rim: $ 552.95) Name and address of Witnesses, Doctors and Hospitals:
p: (323) 596-4629
"Preterred Towing" 210w. 131st St, los Argeles, A 9006
READCAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X" and by showing house numbers or distances to street comers.
NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
CUL
7^1
FOR OTHER ACCIDENTS
Grande
SIDEWALK
CURB/
washington blud
CURB ›
PARKWAY
SIDEWALK
7/ Grande vista
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:
elationship to Claimant:
Alexandra Alvarado exmara 2/23/23
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 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) Buena Park
Honda
I HONDA
TURN/REFUND POLICY: ALL RETURNS MUST BE ACCOMPANIED BY THIS INVOICE AND ARE 6411 Beach Blvd. JBJECT TO A 15% RESTOCKING CHARGE. RETURNED ITEMS MUST BE IN THE ORIGINAL UNOPENED Buena Park, CA 90621 OX OR CONTAINER. PLEASE NOTE THAT THE DEALERSHIP WILL NOT ACCEPT RETURNS OR MAK (714) 690-8455 • Fax (714) 690-8466 EFUNDS AFTER 30 DAYS. NO REFUNDS OR RETURNS ON SPECIAL ORDER PARTS OR ELECTRICA PARTS
DATE ENTERED YOUR ORDER NO. DATE SHIPPED INVOICE DATE INVOICE 23 FEB 23 22 CIVIC SPA 23 FEB 23 NUMBERQ397064 23 FEB 10:36 **QUOTE**
ACCOUNT NO. P98 PAGE 1 OF 1
H
CASH RETAIL - д.
CA 90621
SHIP VIA SLSM. B/L NO. [TERMS F.O.B.
2HGFE2F53NH55 461 CASH BUENA PARK, CA
ORD SHIP B.O. PART NUMBER DESCRIPTION BESI NET AMOUNT
1 1 42700-T20-A71 W-DISK (1 463.18 463 . 18 463.18
CORE EXCHANGE 50.00 50.00
**** INVOICE QUOTE - DO NOT PAY ****
DISCLAIMER OF WARRANTY:
LE IDISCLAIMS PARTS 513.18
NTABILITY AND
NEITHER ASSUMES SUBLET
NOBAUTHARIZS ANY OTHER MASONIC ASSUM AOR E ANY LIABILITY IN CONNECTION WITH THE SALE FREIGHT 0.00 AN END NADAM ARE DAMORO POPE DETES OF LOSS OF USE, LOSE OF TEM SALES TAX 39 77 LOSS OF PROFIT OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES. THIS DISCLAIMER IN NO WAY AFFECTS THE PROVISIONS OF ANY MANUFACTURER OR DISTRIBUTOR WARRANTIES. TOTAL $552.95 Malore AD mia cok cindat ite
BRITE WHITE TIRE
Tires • Wheels • Brakes • Alignment
8225 EASTERN AVENUE
LIC BELL GARDENS, CA 90201 86253
041509) 927-6733
DATE 2023.
Customer Sandra
Odometer
Mileage Warranty
+ 235-10218
3 4
-5- Needs 160
6 herinelt
7 S Bac $450
8 9
10 11 includ
NO ROAD HAZARD GUARANTEE. • NO WARRANTY ON USED TIRES
BRITE WHITE TIRE
Tires • Wheels • Brakes • Alignment
8225 EASTERN AVENUE
TELL GARDENS, CA 90201 86339
(562) 927-6733
DATE 1-23 2023
Customer
Odometer
Mileage Warranty_ 1
2) 23<40 18
3 G000
Tav tun
24000
NO ROAD HAZARD GUARANTEE. • NO WARRANTY ON USED TIRES
(АДА
PREFERRED
Roadside
TOWING Assistance
Provider
210 W. 131st St,
Los Angeles, CA 90061 Independent
P: 323-596-4629 Service
[email protected] Provider
Thank you for your business,
it has been our pleasure to serve you today
Our Goal is to have you
TOTALLY SATISFIED
If you are not TOTALLY SATISFIED
we want to know why, please contact us at
323-596-4629
or Email us at
[email protected]
Once Again
DEFE Thank oF You Business
TOTALLY SATISFIED