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 RECEIVED 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) SEP 25 2023
3. Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom. CITY CLERK DEPARTMENT 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)
30 Gabriela Nubia Rojas Palacion sata
Home Address of Claimant Home elenhone Number
Business Address of Claimant City and State Business Telephone Number CA 90255
Give address to which vou desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
I was driving Southbound on Ahameda St-and before
approaching 24thd25 251 street I hit a pothole.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
The damage occured on March 25, 2023 at approximaldy 12-36a.
Where did DAMAGE or INJURY occur? Describe fully, andlocate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks The damage occured on Alameda and 24th street
What particular ACT or OMISSION do you claim caused the injury or damage? Give namesof City employees, if any, causing the injury or damage, if known:
The damage was caused by the potholes in the streck.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed My vehicle's right frout tire was damaged due to the
potholes and weeded to be replared with a new fire
What AMOUNT do you claim of each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
The amount that I an claiming is 1468.04 - See Attachmet Give ESTIMATED AMOUNT as far as knownyou claim on account of each item of prospective injury or damage, giving basis of computation N| A
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
No
=xpenditures made on account of accident or injury: (Date - Item) (Amount) Expenditures total 11 468-04 - See Attachment.
Name and address of Witnesses, Doctors and Hospitals:
N/A
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
JL
711/1
FOR OTHER ACCIDENTS
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SIDEWALK
CURB/ - 2573 Pothole Alameda
PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signáture of Claimant or person filing on his/her behalf, giving Date:
relationship to Claimar
Nubia Rosas 8 3 2
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO J HEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (C EN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV. CØDE 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 Retail Invoice Store# 003964
191944 Firestone
In: 03/27/23 11:24AM
Emailed on 03/27/2023 since 1926 COMPLETE AUTO CARE™ Out: 03/27/23 03:57PM Emailed to
www.FirestoneCompleteAutoCare.com Business License: REG#ARD222556 Cust Status: Drop Off Appt: No FINAL INVOICE EPA#CAL000365502 9030 CECILIA ST, DOWNEY, CA. 90241-3921 - 562.869.1597
Service Advisor: 1 PRISCILLA Wheel Lock: Technician: 10 JOHN Customer Details: Alt. Auth. Name & Phone: Vehicle Details:
ROJAS, NUBIA 2022 INFINITI Q60 LUXE
N/A
HUNTINGTON PARK, CA 90255-2942
VIN #:
LIC #:
MILEAGE: 1,561
Rev Hist Unit Extended Job
Description (Article # ID Qty - Price Price Total
COURTESY CHECK 01
Battery Test Results:Your battery is measuring within the manufacturer's specification for required CCA. Your battery has sufficient power and should reliably start the vehicle.
You're recommended to have your battery tested after 90 days.
COURTESY CHECK 7046930 10NN 1 N/C N/C
CONTINENTAL TIRE PACKAGE 01 426.73
0356155000 CONTACT 255/40196 7099717 10TN 1 406.99 406.99 No Mileage Warranty
DOT# 16Y03FFTR2322
CA STATE TIRE MANAGEMENT FEE 7046655 10NN 1 1.75 1.75
NEW TIRE WHEEL BALANCE LABOR 7013632100N 1 11.99 11.99
SCRAP TIRE RECYCLING FEE 7075078 10TN 1 6.00 6.00
LOW PROFILE TIRE INSTALLATION 700647210NN 1 N/C N/C
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-35, RF-35, LR-35, RR-35.
All parts are new unless otherwise specified.
Payment History: Summary:
CFNA 8759 468.04 025700 Sale Parts 406.99
Labor 19.74
Term: 0003 Manual Entry Shop Supplies 0.00
Total Tendered 468.04 Sub-Total 426.73
Tax (10.00%) 41.31
Total $468.04
CFNA'S current promotional financing terms, pricing information such as APR and fees, and Credit Card Agreement can be viewed at CFNA.com, Privacy and Legal page.
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# 003964
191944 Firestone In: 03/27/23 11:24AM
Emailed on 03/27/2023 since 1926 COMPLETE AUTO CARE" Out: 03/27/23 03:57PM Emailed
www.FirestoneCompleteAutoCare.com Business License: REG#ARD222556 Cust Status: Drop Off Appt: No FINAL INVOICE EPA#CAL000365502 9030 CECILIA ST, DOWNEY, CA. 90241-3921 - 562.869.1597
I have received the above goods and/or services. If this is a credit card purchase, I agree to pay and comply with my cardholder agreement with the issuer. MOTORIST
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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 003964-191944 Information on service warranty, maintenance, and safety can be located at https://www.firestonecompleteautocare.com/maintain/service-warranty-options/ Inv1_WP 11.14.2022.002
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