CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No. _
INSTRUCTIONS
1. RECEIVED
than six (6) months after the occurrence. (Gov. Code Sec. 9112)
2. after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing. SEP 25 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.
6. Attach separate sheets. if necessary, to give full details. SIGN EACH SHEET. CITY CLERK DEPARTMENT
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)
lennifer Beas 31
Home Address ollelaiman oliv and State Ibme elenhone Number Business Address of Claimant Gly 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 ( As I was driving home after work, I was driving on the
left lane, east towards 710 wy. when object striked my
Vehicle. It was a steel metal from rail road track.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
September 110, 2023 Saturday l0:26 am.
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:
Train tracks located on 4154 Bandini Blud, Vernon Ca 90058 What particular ACT or OMISSION do you claim caused the injury or damage? Give names of City employees, if any, causing the injury or damage, if known:
Negligence to maintain rail road track on proper working condition.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
front bumper damage, front license damage, Exhaust damage. malE damage any magon to datong dam, guing basist
computation:
Est. $850.00 so far expense to make my vehicle
basis of computation:
damage would be for front bumper /paint and
tront license plate.
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
State Furm Policy Number
muney has been received. I did Not Notify insurance.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) $ 18000 on essential parts to drive Vehicle 9/18/2023
Name and address of Witnesses, Doctors and Hospitals:
N
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 you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or your 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
71171
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
CURBY
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:
Jenniter Beas 9/19/2023
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) Rov. 8/4/16
SERG TOUTOR REMOTERES
SERVING YOU FOR OVER 10 YEARS 8200
6271 Whittier Bivd., Los Angeles. CA 90022
Tel: (323) 725-7171
OPEN: Monday to Friday 9:00 A.M. to 6:00 P.M.
Saturday 9:00 AM. to 5:00 P.M
IF WE CANT FIX IT, WE WONT CHARGE YOU
IF WE DON'T HAVE IT WE CAN FIND IT
Name Date.
Addre CATAL REP. 200
City
TYPE OF CAR
DESCRIPTION PRICE AMOUNT
OrY.
Brand New Radiator
New Record
Reconditioned Radiator
New Heaters
Batteries Lic # 230748
Rod Out Radiator
Radiator Repair
Muffler Repair
Mufflers
Lel
Pipes
Catalytic Converter
Chrome Tips
NO RECEIPT NO GUARANTEE
No Recibo No Garantia
ON CATALYTIC CONVERTER THE GUARANTY
IS NOT VALID IF THE CATALYTIC IS BURNED
OR CLOGGED [LABOR
ONLY ON MANUFACTURER DEFECT.
TAX
La garantia no cubre si al cataltico esta
DISCOUNT
quemado o tapado
Solo en defectos de fabrica.
NO REFUNDS ON PARTS EXCHANGES ONLY. TOTAL 1803
WARRANTEE: / 90 LANS
WARRANTEE: MUST BE WRITTÉN ON INVOICE TO BE VALID.
Covers repair on work done only in radiators, or (other work written on invoice). All warrantee wark to be done at 6271 Whittler Bid. Les Angeles, CA 90022. Warrantee is void when taker to mothere pair sea overhe dog get coc engie can cause severe danage at cetomer, expense. (warrantee does not coyer this situation.
Authorized by: 02l 9/18/27
Date