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. MAR 2 3 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.
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)
SAMOnA PEREZ
Home Address of Claimanti Cily and Slate 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:
SIA
How did DAMAGE or INJURY occur? Give full particulars.
I wAsdeNin enlin the mornig, during thE RAIN Storm. I
drovE ovER whAt I thaghtwas water on tharoad. Howeven It WAS ABig pothole fillad with waten thRoken piecEs of thenoa When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.: Stickyat 3/21/23 :30 AM
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:
1905 E 72NST. VERNoN
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:
Give full extent of injuries or damages claimed:
SUfARDAMAgE OI1 PAN, UndERnEATh CARAgE.
I'm Still WArtagoN HondA dEALERS dIAgnost.C
Nhat AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basiso Whitus on HondA dealeR on Amant
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
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/ STATE FARM 1,003.78 YEAR
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
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.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself NOTE:If diagrams do not fit the situation, altach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
7^171
FOR OTHER ACCIDENTS
///L
CURB/
CURB›
77 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:
CAmonA YEnE 3|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 ANTINA DV TUE AITV AE TUIC CI AIM INITIIN AE NAVE AE EII INA TUCA TUIE AI AIM IC NEEMEN NENIEN /CEE CAl/ AnE CEr 011 6 2 012 1) RAmonA
Penez
20 TF ST- RCE LV
Foodsoppty
POTHOLE
1905y
22Nº ST
-- ALAMEDA - 18758.2200
X ROGERS
prode
22 ND"
Pamen Pey 3/23/2023
Honda 700376
OF DOWNTOWN
Honda LOS ANGELES Honda 700376
780 W. Martin Luther King Jr. Blvd. • Los Angeles, California 90037 213) 234-2130
RECOMMENDED SERVICES www.hondaoflosangeles.com
OPERATION OPERATION DESCRIPTION MO/MITOTAL OPERATION OPERATION DESCRIPTION MO/MI TOTAL
SERVICE HISTORY
DATE REPAIR ORDER MILEAGE ] ADVISOR | TECHNICIAN TYPE | OPERATION OPERATION DESCRIPTION SALESPERSON NO. SERVICE
STATE REG# ACO11203 LICENSE NO
TERMS YEAR MAKE MODEL PRODUCTION DATE STOCK NO.
CASH
17/HONDA/GTYOE SEDAN/ 4PRRCSON EX CVI 700376
HENE CARD SERVICE CONTRACT DELIVERY DATE DELIVERY MILES SELLING DEALER NO. R. O. DA
RAMONA PEREZ
236678 DAC21/23
COLOR CONTRACT NO EXPIRATION DATE EXPIRATION MILES
OTHER
3452
SAVI TURIN) | MME AIR COND PS | TRANS ]MIL EAGE ADVISOR NO ADVISOR REMOVIE TOSCAR PINUELAS.
N HOZZ Y Y A 1 2109
PARSLON MINE S2:1T8 IN
I hereby authorize the repas work therein set forth to be done by you, together with the furnishing by yot of the necessary parts and other COMER material for such repair, and agree: That you are not responsible for any delays caused by unavailablity or delayed availability of parts or material DAL/TIME PREMISED HE HITY for any reason; that you neither assume or authonze any other person to assume for you any lability in connection with such repair: that you shall not be responsible for loss or damage to the above vehicle, or articles left therein; in case of fire, theft or other cause beyond your control:
11:57am 03/21/23 07:00pm That an express mechanic's len is hereby acknowledged on the above vehicle to secure the amount of repairs thereto; that your amployees PAROR AISO nay operate the above vehicle on streets, highways of elsewhere for the purpose of testing and/or inspecting such vehicle
ATTINIMI NI
X
JOB
Consent to be Contacted by Phone Call, Text Message, and Email I consent to the dealership isted above contacting me by phone. in writing, by amal, or by using ORIGINAL CUSTOMER ESTIMATE: TOTAL
190.00
x good or service, and may revoke this consent at any time.
COMMENTS: CUSTOMER SIGNATURE
X010VGSF1H:created 2023-03-21 07:16:00am taken by DIANA RAMALES tow ORIGINAL HAZ. WASTE TOTAL ESTIMATE ESTIMATE S HNLG. 3
ing in leaking no promise time DISP
REVISED ADDITIONAL
ESTIMATE S COSTS
1 C O2HOZTELLUS TELL US MORE
REASON CONTACTED
VEHICLE TOWED IN; CUSTOMER STATES THAT SHE HIT A POTHOLE IN BY DEEP WATER AND CAUSED DAMAGE UNDERNEATH; NOW ENGINE HAS NO DATE TIME
AUTHORIZED L PERSON
OIL DUE TO LEAKED OUT; CHECK AND ADVISE ON NEEDED REPAIRS PHONE 2ND REVISED HAZ. WASTE IDDITIONA
ESTIMATE S HNLG. 8 COSTS
DISP
REASON CONTACTED
2 C 01HOZ21POINTS MULT-POINT INSPECT • PERSON DATE TIME PERFORM HONDA COMPLIMENTARY MULTI-POINT VEHICLE INSPECTION. • PHONE • 3RD REVISED HAZ. WASTE ADDITIONA
ESTIMATE S HNLG. & 'OST S
DISP
REASON
CONTACTED
AUTHORIZED DATE TIME
C 17HOZPSI TIRE PRESSURE CHECK BY PHONE
PERFORM TIRE PRESSURE CHECK - ADJUST TIRES TO FACTORY WE DO NOT ASSUME ESPONSE LITY FOR LOSS OR DAMAGE FOR ARTICLES LEFT The Reynolds and Reynolds Company ERAINTWOZE C6/21760 (06/22 SPECIFICATION - RESET TIRE PRESSURE INDICATOR AS YOUR VEHICLE NECESSARY TEARDOWN ESTIMATE:
NOTICE. By law. you may choose another licensed Smog Check station to perform repairs at https://www.hondaoflosange
ALL PARTS INSTALLED ARE NEW UNLESS SPECIFIED OTHERWISE.
STOMERS
ALL PARTS ARE NEW HONDA ORIGINAL EQUIPMENT PARTS UNLESS SPECIFIED OTHERWISE WE MAKE A SEPARATE OF TOXIC WASTES.
SERVICE AND ARE AVAILABLE ON REQUEST.
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