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.
+ LI See page 2 for diagram upon which to locate place of accident
6. 7.
TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (if natural person)
Antonio Rayo Noguera Yader 31
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:
How did DAMAGE or INJURY occur? Give full particulars.
2 vehicle accident at ARCO gas station, insured V1 was pulling away from Gas Pump when they noticed V2 (Marissa Renee Velez, City of Vernon Official) coming toward V1. Vi stopped and honked but V2 did not stop hung ring com a cople an an a or a i are in buy a ding ring aled When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
damage occurred at approximately 10:30 PM with the Police Report stating 2244 hours on May 20, 2023 here did DAMAGE orINJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Arco Gas Station located at the corner of S Soto and E Vernon with a physcial address of 3031 E Vernon Ave, Vernon CA 90058
What particular ACT or OMISSION do you claim caused the injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
City Official, Marissa Renee Velez was driving city vehicle described as V2 herein and failed to Maintain Propert Lookout and Avoid Distraction prior to colliding with V1.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
V1 sustained moderate damage to front bumber
What AMOUNT do you claimof each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
$1507.05 in Vehicle Damage and $1,200 for Enterprise Rental Car while repairs were completed
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
vehicle Damage - $1507.05, Enterprise Rental Car, Rental Cost - $1,200.00 Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Yes. State Farm Insurance Companies, Policy number - 5805-793-75, Claim number - 75-50G4-94L, SF contact number - 844-292-8615
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
READCAREFULLY
rail accident claims place on following diagram names of streets, including North, East. South, and West: indicate pla accident by X and by showing house numbers or distances to street come NOTE:it diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
I LILI
7117 /
FOR OTHER ACCIDENTS
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:
Yader Rayo Noguera 08-28 - 23
VOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER CATA. PRESENTATIÓN OF A FALSE CLAIM IS A FELONY (CAl EN. CODE SEC. 72). CLAIMS MUST BE FILEDWITH CITY CLERK (GOV.CODE SEC. 815a). 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. B/4/16