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. JUN 05 2023
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
1. 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)
Evelin Meza 24
Ta andanta MAma talonhone Naimber
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:
How did DAMAGE or INJURY occur? Give full particulars.
Driving down washington Blrd at the speed of 40 MPH driver was not able to avoid rectangular void on the middle of the lane.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
January 10,2023 at around 6:07 PM
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:
n front of 4260 E. Washington Blvd Los Angels CA 90023 driving west Vhat particular ACT or OMISSION doyou claim causedthe injury ordamage? Givenamesof City employees, if an causing the injury or damage, if known:
There was a rectangular void right in the middle of the street, it was exactly a rectangle and appeared as if work had been done and void had been left uncovered.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
There was damage to my vehicle which included a tire blowout, bent rim, and scratched/ bent bumper. and under neath front (spoiler).
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$ 303.15 Michelin tire $408.00 spoiler Total$hi, 857.15 $ 596.00 Wheet rim $550.00 dent and paint repair
Give ESTIMATED AMOUNT as far as knownyou 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:
Insured by Allstate, do not want to report
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.
NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
-west
Washington Bivd
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
CURB y
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:
Evelin Meza relationship to Claimant:
06105123
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UIDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL '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 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 & 9124) Rev. 8/4/16