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) 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. MAR 2 0 2023
See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom. CITY CLERK'S OFFICE 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 (If natural person)
Doron Davidian /Unlimited Beauh Cone
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number 3825 S Santa Fe éAve. Vernon 1A 90018
Give address to which you desire notices or communications to be sent regarding this claim:
3825 S. Santa fé Ave.. Vernon cA 90018._
How did DAMAGE or INJURY occur? Give full particulars.
ae to a heavy storm and astrong air the tree infront
of the company tell and undid the Handrail and Knocked
down some bricks.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
We dare the
Saturday Febrar th in the eady mornin (damage at 7:00 am) Where did DAMAGE or INJURY occut? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Between . 38th st. and E. Vernon Ave.
What particular ACT or OMISSION do you claim caused the injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
It was not because of man it was because of Weather.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed = Handrail
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
- Handreil = 750.-
BUcks 200.-
Give ESTIMATED AMOUNT as farasknown you claim on account of each item of prospective injury or damage, giving basis of computation:
Tobt Claim a 950.-
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) Doesnit ApPL
Name and address of Witnesses, Doctors and Hospitals:
Doesn't Applo
READ CAREFULLY
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 corners.
NOTE: if diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
LILU
FOR OTHER ACCIDENTS
3825
SIDEWALK
3B25 South Santa jé Ave St
CURB/
CURBy
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 to Claimant:
DORON DAVIDIAR 03-20-23
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)