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) RECEIVED
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 MAY 202024
See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom.
Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. CITY CLEM BLINKE 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)
DAVID HORN 60
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:
Same as above
How did DAMAGE or INJURY occur? Give full particulars.
See Attached
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
02/05/2024 occurred at approximately 2 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:
On 27TH Street between Santa Fe Blvd and Alameda 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:
See Attached
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
I had to replace the front axle and the cracked torque mount, which has not been repaired yet.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
The front axel cost $580.00. The cracked torque mount cost is $400.00 Give ESTIMATED AMOUNT as farasknownyou claim on account of each item of prospective injury or damage, giving basis of computation:
The front axel cost $580.00. The cracked torque mount cost is $400.00 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. Insurance company is AAA. Policy number: - They did not reimburse me Expenditures made on account of accident or Injury: (Date - Item) (Amount) $580.00
Name and address of Witnesses, Doctors and Hospitals:
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.
NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
7^171
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:
DAVID I. HORN relatienship to Claimant:
MAy 12,24
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 & 9124) Rev. 8/4/16
CLAIM FOR DAMAGE
David Horn
How did DAMAGE or INJURY occur?
The damage to my car occurred while driving on E 27th Street as stated above.
My vehicle sustained significant damage due to the frequent and severe potholes on the road.
My vehicle was damaged due to the numerous potholes on East 27th Street between Alameda Street and Santa Fe Avenue. Despite my efforts to avoid this road, I often have to travel on it to reach my destinations efficiently. The severity and frequency of the potholes make navigation hazardous, leading to damage to my vehicle.
Where did DAMAGE or INJURY occur?
I claim that the city or its contractor failed to adequately maintain East 27th Street between Alameda Street and Santa Fe Avenue, resulting in hazardous road conditions with numerous potholes. These poor road conditions directly led to the damage to my vehicle.
CLAIM FOR DAMAGES
DAVID HORN
FZ GARAGE 01286
REPAIR ORDER
321 S Highland Avenue
Fullerton, CA 92832
Job Number (714) 204-0223
Job Name
Part Number & Description Price Amount @fzgarage911
Qty.
Name Customer Order No. Date
Address Order Written By Promised
AM
PM
Day Phone Ext. Evening Phone Odometer In
Year, Make, Model License No. Odometer Out
IS Fos EDGE
Serial No. Motor No. Terms
Description of Work Amount
-
•Lube •Change Oil DOil Filter •Tune-Up •Trans. •Diff.
LOO HACED AX/EV. , e
Demoven
for turnes Ratoru
GoiC
(May be continued on other side) Liters/Gals. of Gas @ Total Labor Total Parts
• 00
Total Parts 460
Accessories Liters/Qts. of Oil @
Accessories
kg/Lbs. of Grease of Oil @
Gas, Oil and Grease
Sublet Repairs
I hereby authorize the above repair work to be done with the EPA/Waste Disposal necessary materials. You and your employees may operate above vehicle for purposes of testing, inspection, or delivery at my risk. An express mechanics lien is acknowledged on above vehicle to secure the amount of repairs thereto. It is understood that you will not be held responsible for loss or damage to vehicle or articles left in vehicle in Tax case of fire, theft, or any other cause beyond your control.
Save Old Parts? •Yes •No
Total Accessories Signature
Thank You
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