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)
3. Read entire claim before filing FEB 13 2024
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. 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)
Sared Austin Dickerson 43
Home Address of Claimant
Home Telephone Number
business Address or Claimant City and State Business Telephone Number 271Ø N. Harbor Drive San Diego, CA. 12101 619-278-7069
Give address to which vaul desire naticas or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
Saturday, February 3rd at 8:40pm I was driving on Santa Fe. At The intersection of Olympic Blud and Santa Fe. There was a deel pothole I hit and popped two Driver's Side tires. When I pulled over, there was two other Cars changing a tire each. The pothole is does and it's on th pedestrian walk way.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Saturday, February 3rd at 8:40pm
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where Olympic Bl and Santa Fe. Across
is located on pedestrian
causing the injury or damage, if known:
The pothole popped two fires, it's extremely deep
otner people popped atire too! 3 vehicles In 15 minutes.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Just car damage, no personal injuru-
computation: Total Amount What AMOUNT do you claim of each item of injury or damage as of date of presentation of thiş claim, giving basisof Of two fires, with labor & taxes total
Sum is # 1,124•38
basis of computation: Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving Jared Dickerson Jaul Dim 06FEB2024
Nere you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received: e, - have WAR Insurance or my Car. Did not file inurance.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) none / NA
Name and address of Witnesses, Doctors and Hospitals:
none
K
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 comers.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself r your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or you 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
FOR OTHER ACCIDENTS
Shell
Gastation
сияв)
E Olympic BL. → CURB;
PARKWAY
SIDEWALK
pedestrian
walk.
Lurge Pot
hole is black
Dot.
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 relationship to Claimar
Jared Dickerson and Din 067EB2024
ITU DDESENTATION OF A FAI SE CLAIM IS A FELONY (CAL
Tesla, Inc Invoice Invoice date Invoice number
1200 W Main St 04-Feb-2024 3000S0009213815
Alhambra, CA,US 91801-3329 SERVICE DEPARTMENT HOURS
Mon-Fri 8am - 6pm Due Date
Ph.: (626) 313-5967 Saturday-Sunday Sat:8am- 04-Feb-2024 TESLA
6pm,Sun:Closed
Date/Time Received Date/Time Promised
03-Feb-2024 21:54:34 04-Feb-2024 12:30:46
Paid B.A.R.# ARD00281719
Odometer In Odometer Out
Miles Miles
Ready Date
04-Feb-2024 12:07:03
Service Advisor
Serena Estrada
Bill To Mobile Phone Additional Phone Vehicle Identification Number Jared Dickerson
Year Model License Plate Number Colour
2023 MODEL 3 Midnight Silver Metallic
Job Number Description Of Work Amount (USD)
Concern: Check tire pressure and condition
Repair Notes: Automated tire pressure check (adjustment needed). All tire pressures set to factory recommendation. No further adjustments needed at this time. 1 Correction: Automated Tire Pressure Check (Adjustment Needed) Pay Type: Goodwill - Service
0.00 2 Concern: Multiple Flat Tires Wheels Impacted: Front Driver, Rear Driver 1,035.00 Repair Notes: Verified the customers concern. Removed and replaced front and rear LH tires per tesla service instructions. Verified proper air pressure, balance and tire tread. Re-learned tpms.
Performed validation test drive to verify proper function. No further adjustments needed at this time.
DOT 1UN 9K280K 1523
DOT 1UN 9K280K 1523
Correction: Tire - Rear - LH (Remove Labor Hours Price Adjustment Subtotal & Replace) - Remove and Replace
0.30 76.50 0.00 76.50
Parts Replaced or Added
Part Quantity Unit Price Price Adjustment Subtotal
TIRE, 235/35R20 92Y 1.00 436.00 436.00 0.00 436.00
XL PIRELLI SUMMER
PZ4(1044257-00-A)
TIRE DISPOSAL 1.00 5.00 5.00 0.00 5.00
FEE(1025331-00-A)
Parts Subtotal 441.00
1 of 4
Correction: Tire - Front - LH (Remove Labor Hours Price Adjustment Subtotal & Replace)
0.30 76.50 0.00 76.50
Parts Replaced or Added
Part Quantity Unit Price Price Adjustment Subtotal
TIRE, 235/35R20 92Y 1.00 436.00 436.00 0.00 436.00
XL PIRELLI SUMMER
PZ4(1044257-00-A)
TIRE DISPOSAL 1.00 5.00 5.00 0.00 5.00
FEE(1025331-00-A)
Parts Subtotal 441.00
Pay Type: Customer Pay
Total Parts Amount 882.00
Total Labor Amount 153.00
Labor Hours 0.60
Concern: Multiple Flat Tires Wheels Impacted: Front Driver, Rear Driver Repair Notes: Verified the customers concern. Removed and replaced front and rear LH tires per tesla service instructions. Verified proper air pressure, balance and tire tread. Re-learned tpms.
Performed validation test drive to verify proper function. No further adjustments needed at this time.
DOT 1UN 9K280K 1523
DOT 1UN 9K280K 1523
3 Correction: Perform Post-Repair Validation Test Drive Pay Type: Basic Vehicle Limited Warranty
0.00 Service Center hourly rate: USD 255
Notes: To assess your vehicle's Tire Wear and Condition, please see the Tire Care and Maintenance section from the digital Owner's Manual in your car.
Total Parts (USD) 882.00
All parts are new unless otherwise specified
Total Labor (USD) 153.00
Accepted Payment Methods:Major Credit Cards (Visa, Mastercard, AMEX, etc.), Debit Discount 0.00
Card, Cashier's Check
Subtotal (USD) 1,035.00
You agree that: You are entitled to a price estimate for the repairs you have authorized. The Tax 89.38 repair price may be less than the estimate but shall not exceed (1) any price limited estimate or (2) any parts and labor estimate by more than 10%. Additional repairs may not Total Amount (USD) 1,124.38 be performed without your consent. This estimated price for authorized repairs will be Amount Due From
0.00 honored if your vehicle is delivered to Tesla's facility within the time periodagreed to by you Customer (USD) and Tesla. You may waive your right to a written estimate and require that you be notified if Paid by Customer the price exceeds an amount you have specified. Tesla is not responsible for any personal 1,124.38 (USD)
items left in your vehicle; Tesla and its employees may access and operate your vehicle including on streets, highways, or public roadways for the sole purpose of testing and/or inspection of repairs; Tesla may update your vehicle's software in the course of a repair or as part of the standard vehicle maintenance process per your owner's manual and New Vehicle Limited Warranty; Tesla and its employees may access, download and use the information stored on your vehicle's data recorder to service and diagnose issues with your vehicle, and Tesla may store and aggregate such data for its own purposes; an express mechanic's lien is hereby acknowledged on your vehicle to secure the amount of repairs. storage and other applicable fees; the vehicle owner's insurance provides exclusive coverage for the vehicle while it is in Tesla's possession; and you may be charged storage 2 of 4
fees of $35/day from the fourth working day after you are notified that repairs on your vehicle are complete and that the vehicle is ready for pick up.
Tesla disclaims all express or implied warranties with respect to any repairs or products used in repairs, except as may be set forth in your Tesla-issued New or Used Vehicle Limited Warranty, Tesla Parts, Body, and Paint Repair Limited Warranty or other extended service agreement. Tesla is not responsible for repairs not performed by, or components not installed by, Tesla. Any parts (including tires/wheels) removed or replaced by Tesla during vehicle service will become the property of Tesla. However, at the time you authorize repairs, you may request to receive (subject to any applicable core charge, which you agree to pay) or inspect replaced parts (excluding inflatable restraint system components), except body shop repair parts and parts required to be returned to the manufacturer or a third party under a warranty, trade-in or exchange agreement, which will only be presented to you for examination and not returned. 1 authorize the repair work, including parts, materials and labor, on my vehicle to be done pursuant to the terms and conditions as set forth in this service agreement document.
Signature: Date:
Warning:Motor vehicles contain chemicals known to the State of California to cause cancer and birth defects or other reproductive harm.
FullName: Jared Dickerson
A buyer of this product in California has the right to have this product serviced or repaired during the warranty period. The warranty period will be extended for the number of whole days that the product has been out of the buyer's hands for warranty repairs. If a defect exists within the warranty period, the warranty will not expire until the defect has been fixed. The warranty period will also be extended if the warranty repairs have not been performed due to delays caused by circumstances beyond the control of the buyer, or if the warranty repairs did not remedy the defect and the buyer notifies the manufacturer or seller of the failure of the repairs within 60 days after they were completed. If, after a reasonable number of attempts, the defect has not been fixed, the buyer may return this product for a replacement or a refund subject, in either case, to deduction of a reasonable charge for usage. This time extension does not affect the protections or remedies the buyer has under other laws.
You further agree and acknowledge that:
• You have the right to inspect your vehicle on Tesla premises prior to payment • Tesla is not responsible for loss or damage to the vehicle or any articles left in the vehicle in case of fire, theft, hail, wind, or any other causes beyond its control;
•Tesla personnel will turn off any photo or video capturing devices, such as dashboard cameras, once they receive the vehicle in preparation for service and your vehicle's Tesla dash cam will be enabled when you pick up your Tesla from this Service visit; • Labor charges are not based solely on actual service personnel's time but are aggregate prices for specific services or repairs, which may include flat rates based on industry manuals and vehicle condition; • Waste storage and disposal fees are charged separately when applicable to specific services or repairs, and represent costs and profits to Tesla which are calculated based on average annualized costs across Tesla service facilities; • Items purchased over the counter or online directly from Tesla may be returned within 30 days with a proof of purchase and must be in their original and uninstalled condition with factory labeling attached and in factory packaging (if supplied); •Tesla-branded parts purchased directly from Tesla over-the-counter, online or purchased and installed by Tesla Service are covered under the Tesla Parts, Body, and Paint Repair Limited Warranty for a period of 12 months subject to the applicable terms, conditions and exclusions and available at https://www.tesla.com/support/vehicle-warranty; • All charges for repairs, including labor, parts and materials furnished, are due and payable simultaneously with the return of your vehicle or prior to return upon the expiration of three (3) working days after notice has been sent by Tesla that the vehicle is ready:
• If applicable, you have the right to choose the licensed repair shop where the damage to your vehicle will be repaired; • All crash parts supplied meet the standards used in manufacturing the original equipment replaced; • If any repair, storage and other applicable fees remain unpaid for thirty (30) days after a request for payment, Tesla may pursue collection and you will be responsible for paying all reasonable attorney's fees and costs for such collection; • If provided a loaner or rental vehicle, the vehicle must be returned within 24 hours of such notification or a daily usage rate of up to $100 USD and applicable fees will be charged until the return of such loaner vehicle; • The repair work may not be completed prior to the date and time noted under Date/Time Promised and Tesla may adjust the estimated completion date upon notification to you and is not responsible for any delays caused by the unavailability of parts or parts • Tesla (and any of its subsidiaries) may contact you via emails, calls, SMS or other messages including through the Tesla app (collectively, "messages") to obtain authorization and provide updates regarding this Service visit and your vehicle. Standard SMS 3 of 4
message and data rates may apply. You can withdraw your consent to receive automated SMS messages at any time by replying "STOP"or providing written notification to Tesla's customer representative. 4 of 4