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 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
5. This claim form must be signed on page 2 at bottom.
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)
Maria Ra LuiSA Mendoza 48
Home Address of Claimant Gity and State Homo donban Nimbor Business Address of Claimant Citv and State Business Telephone Number 323-2-44-54-02
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars
The damaged occured when my Vehicle was parked outtide my Work, and lignting struck a utility pole with power lines causing the fragments to Fall on my car and breaking the sunroof of my car.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Ine Damages occur wednesday 03122123 11:30 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:
The Deanegas The Damage occur on city verare vernon
Street District BIvo
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:
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Se le quebro el quemacocos
What AMOUNT do you claim of each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
1,599.95
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
The estimated amount is 1,599.95 dellars For Damages.
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) 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 corners. i City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourse ehicle at the time of accident bu yand the point of ele at me of accident by "A-1" and location of yourself or you NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
J LILL
7^Г
FOR OTHER ACCIDENTS
Bon Appetit
///L Work Bakery
SIDEWALK
CURB/
District Blud CURB,
DuOT 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:
relationship to Claimant:
laria 03124123
viSc Men, 0 LC
VOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CA EN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV. CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF AN' ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 9124) no. man
MIKE'S FAST GLASS Copy 1
7401 SO.ALAMEDA ST.
LOS ANGELES, CA 90001
PH:323 583-0219 FAX:323 583-6992
P/O#: Cust State Tax ID: Quote: Q004487
Chip Fed Tax ID:
Taken By: 09:29 AM
Installer
SalesRep: OMAR Adv. Code:
MARIA LUISA MENDOZA MARIA LUISA MENDOZA
Vehicle Information
Make: Nissan Model Style: Rogue 4 Door Utility Year: 2021 Odometer: VIN: License:
Qty Part Number Description List Disc% Sell Total
1 FW05638GTYNCOM SUNROOF GLASS *$1,210.00 $1,210.00 $1,210.00 WIWSLAB Domestic W/S Labor (0 Hours) $275.00 $275.00 $275.00 1 HAH000004 Adhesive-(2.0, Urethane,Dam, Primer) $0.00 $0.00 $0.00 '*' Indicates User Altered List Price
Install Date: 03/24/23, In Shop
Instructions:
THIS IS NOT A RECEIPT .. DO NOT PAY
Sub Total: $1,485.00
Tax: $114.95
Total: $1,599.95