CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
• Claims for death, injury to person or to personal property must be filed not late RECEIVED han 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) AUG 2 X. 2023
3. Read entire claim before filing.
4. See page 2 for diagram upon which to locate place of accident CITY CLERK'S OFFICE This claim form must be signed on page 2 at bottom
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 of Claimant Age of Claimant (if natural person)
Sandra Dolson 57
Home Address of Claiman 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:
How did DAMAGE or INJURY occur? Give full particulars.
On 8/20/23 at approximately 8 pm | was driving on Downey Blvd. and due to the heavy rain I was not able to see a pothole which damaged one of my tires. Also, metal debris cut through the tire (picture attached)
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
8/20/23 around 8 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:
In the area of the 5683 block of Downey Blvd
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:
poor road maintenance
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
damaged tire had to be replaced
What AMOUNT do you claimof each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$141.50
Give ESTIMATED AMOUNT as farasknown you claim on account of each item of prospective injury or damage, giving basis of computation:
$141.50
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
N/A
Expenditures made on account of accident or Injury: (Date - Item) (Amount) N/A
Name and address of Witnesses, Doctors and Hospitals:
David Dolson
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
//L
SIDEWALK
tot hole
harp obeet
CURB
Downe- 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:
Sandra Dolson relationship to Claimant: 8/21/23
Ala
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 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
MAYWOOD TIRE SERVICE
TEL/FAX: (323) 589-6077
6221
3500 EAST SLAUSON AVENUE MAYWOOD, CA 90270
Customer's Order No. Phone No.
081211/23
Sold to
Address
City State Zip
Sold By Cash C.O.D Charge On Acct. Mdse.Retd. Paid Out
MAYWOOD TIRE SERVICE QTY. Description Price Amount
3500 SLAUSON AVE
MAYWOOD, CA 902702527
08/21/2023 1 Va Ti 1140-
09:27:49
CREDIT CARD
VISA SALE
Card # 1215/55/17
Chip Card: CHASE VISA
AID: A0000000031010 Fovture
SEQ #: 15
Batch #: 172
INVOICE
15 Approval Code: 02491C
Entry Method: Chip Read fruit (we
Mode:
Issuer
SALE AMOUNT $141.50
All claims and returned goods MUST be accompanied
by this Bill. TAX
CUSTOMER COPY
Rec'd #140-
Total
By
Thank You!