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 9 2023
4. See page 2 for diagram upon which to locate place of accident 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)
Carol Bullock 65
Home Address of Claimant City and State I Home Telenhone Number Business Address of Claimant City and State Business Telephone Number 3840 E 26th Street Vernon, CA 90058 501-891-5635
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
March 27th around 3:30pm leaving my Vernon office at Revolution I hit a Large pot hole which caused a flat tire. I took car to Firestone Tire in Huntington Park. I had to leave my car at Firestone overnight. Paid for Uber from Firestone to home, 3/28 Uber from Home to Vernon Revolution office and in the afternoon Revolution Office to Firestone.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
March 27th around 3:30pm on 26th street between 3840 E 26th street and Soto (going west) 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:
Large pot hole on 26th caused instant Flat tire. Between 3840 E 26th Street and Soto Street (going west)
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:
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Flat tire $292.43, Uber 3/27 $41.97, Uber 3/28 $38.37 and Uber $14.95. Grand Total $387.72 What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
Total damage and cost to have tire replaced $292.43 plus Uber charges $95.29 TOTAI $387.72 Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
Grand Total tire and Uber $387.72
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) 3/27 uber $41.97. 3/28 uber $38.37 and $14.95 and Firestone $292.43 $387.72 Name and address of Witnesses, Doctors and Hospitals:
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
71171
FOR OTHER ACCIDENTS
SIDEWALK
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cuRB/ 26 vect
CURB 1
PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Slatious 91 arman or person fling on fisher beal, g ing Date:
Carol Bullock 3/29/2023
OTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (C N. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV. CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF A 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) Rev. 8/4/16
Retail Invoice Store# 002569
173393 Firestone In: 03/27/23 04:15PM
Emailed on 03/28/2023 Out: 03/28/23 03:33PM
since 1926 COMPLETE AUTO CARE™
www.FirestoneCompleteAutoCare.com Business License: REG#ARD222577 Cust Status: Waiting Appt: No FINAL INVOICE EPA#CAL000365563 2651 E GAGE AVE, HUNTINGTON PARK, CA. 90255-4140 - 323.587.6214 Service Advisor: 5 OCTAVIO Wheel Lock: Technician: 01 JOSHUA Customer Details: Alt. Auth. Name & Phone: Vehicle Details:
BULLOCK, CAROL 2016 BMW 2281 BASE
N/A
LIC #:
MILEAGE: 76,367
Rev Hist Unit Extended Job
Description /Article # ID Qty Price Price Total
PIRELLI TIRE WITH RUN FLAT, PACKAGE 05 266.90
NEW TIRE WHEEL BALANCE LABOR 7013632 01NN 1 12.99 12.99 TPMS VALVE SERVICE KIT LABOR 7008190 O1NN 1 3.17 3.17
6-231C TPMS KIT VS70 7012743 01TN 1 7.00 7.00
SCRAP TIRE RECYCLING FEE 7075078 01TN 1 6.00 6.00
LOW PROFILE TIRE INSTALLATION 700647201N 1 N/C N/C
7099416 CINTURATO P7 205/50R17 7099416 01TN 1 235.99 235.99 DOT# 93NTP65221922
CA STATE TIRE MANAGEMENT FEE 7046655 01NN 1 1.75 1.75
COURTESY CHECK 05
COURTESY CHECK 7046930 01NN 1 N/C NIC
ORDER NOTES
To comply with the California Air Resources Board, We will check and adjust your vehicles tire pressures.
Actual Measured Tire Pressures (PSI): LF-33. RF-33, LR-33, RR-33.
All parts are new unless otherwise specified.
Payment History: Summary:
Visa 0455 292.43 09413C Sale 242.99
MID: 222220326521 Parts
Labor 23.91
Term: 0002 Card Inserted Shop Supplies 0.00
AID: A0000000031010 PIN NOT VERIFIED
Total Tendered 292.43 Sub-Total 266.90
Tax (10.25%) 25.53
Total $292.43
Declined Work:
RENU 500 FUEL SYSTEM CLEANER
Information on tire warranty, maintenance, and safety can be located at https://www.firestonecompleteautocare.com/tires/warranty-options/ or by calling toll free 800-847-3272 to obtain a free printed copy Information on service warranty, maintenance, and safety can be located at
Retail Invoice Store# 002569
Firestone
173393 In: 03/27/23 04:15PM
Emailed on 03/28/2023 since 1926 COMPLETE AUTO CARE" Out: 03/28/23 03:33PM www.FirestoneCompleteAutoCare.com Business License: REG#ARD222577 Cust Status: Waiting Appt: No FINAL INVOICE EPA#CAL000365563 2651 E GAGE AVE, HUNTINGTON PARK, CA. 90255-4140 - 323.587.6214 I have received the above goods and/or services. If this is a AS credit card purchase, I agree to pay and comply with my MOTORIST cardholder agreement with the issuer.
ASSURANCE
PROGRAM
WE SUPPORT
PROFESSONALCERTF CATON
BUILDING TRUST THROUGH STANDARDS
THY DUCH THEI
AUTOMOTIVE Customer Signature
EXCELLENCE
HOW ARE WE DOING?
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Complete a 4-minute survey for a chance to win one of ten $50 gift cards each month! Visit www.FirestoneSurvey.com within 4 days and enter Code 002569-173393 Information on service warranty, maintenance, and safety can be located at
From: [email protected],
Subject: Your Monday afternoon trip with Uber
Date: Mon, Mar 27, 2023 4:59 pm
Frantient tire
Total $41.97
Uber
'to Home March 27, 2023
Thanks for tipping, Carol
Here's your updated Monday
afternoon ride receipt.
Total $41.97
Trip fare $24.13
Subtotal $24.13
Marketplace Fee O $10.00
Access for All Fee e $O.10
CA Driver Benefits O $0.75
'Bulleck
Tips $6.99
Payments
VISA Visa ••••0455 $34.98
3/27/23 4:59 PM
VISA Visa •..-0455 $6.99
From: [email protected], get ques an
To!
Subject: Your Tuesday morning trip with Uber
Date: Tue, Mar 28, 2023 7:17 am Xian hore
to offill in Veron
Total $38.37
Uber Vindatian
March 28, 2023
Thanks for tipping, Carol
Here's your updated Tuesday
morning ride receipt.
Total $38.37
Trip fare $21.13
Subtotal $21.13
Marketplace Fee Pullock $10.00
Access for All Fee ® $0.10
CA Driver Benefits $0.75
Tips $6.39
Payments
VISA Visa ••••0455 $38.37
3/28/237:17 AM
Switch Payment Method
From: [email protected], Turs pm
To:
3te8
Subject: Your Tuesday afternoon trip with Uber
Date: Tue, Mar 28, 2023 3:42 pm
Free tutte fireste
Total $14.95
Uber
March 28, 2023
Thanks for tipping, Carol
Here's your updated Tuesday
afternoon ride receipt.
Total $14.95
Trip fare $8.37
Bullock
Subtotal $8.37
Marketplace Fee $2.73
Access for All Fee $0.10
CA Driver Benefits $0.75
Tips $3.00
Payments
VISA Visa ••••0455 $14.95
3/28/23 3:41 PM
Switch Payment Method