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 APR 2 7 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. 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
Name 10 Age of Claimant (if natural person)
2E GAMBOA
Home Address of Claimant City and State 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:
on 3-73-2 How did DAMAGE or INJURY occur? Give full particulars. 725 AM I was driving East on wastingtongled just Befue Doney read just in front of the driveway of 3222 unashington Bled on thestreet & it Rain
on 3-73-7 hen did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Tire no Good Pop and rim Bended when Ran der pot hole
1 25Au
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:
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: Pothole
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Bad tire Bad rim
What AMOUNT do you claim of each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
websites price
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
RIM 31.00+tax tReast.99 installation fee 79737 425.73
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:
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 If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself or your vehicle when vou first saw City vehicle: location of City vehicle at time of accident by "A-1" and location of vourself or vou vehicle at the time of accident by "8 1" and the point of Impact by "X.
NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
/L
7AT,
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
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:
FredGAMBOA Junk 4-27-23
NOTE ALL CLAMANTS MAY BE REQUESTED TO BE EXAMNED AS TO THEIR CLAM 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)| Rev. 8/4/16
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