CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
Claims for death, injury to person or to personal property must be filed not lat lan six (6) months after the occurrence. (Gov. Code Sec. 911.
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.
4. See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom.
ttach separate sheets, if necessary, to give full details. SIGN EACH SHEE
7. laim 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)
er- Marachelian 68
Home Address of Claimant Olty and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number 4622 k coa Vive vernon CA 90058 323 583 1040
Give address to which you desire notices or communications to be sent regarding this claim:
4622 Alcoa HAve Vernon Cit 90058
How did DAMAGE or INJURY occur? Give full particulars.
The Cry's street sewer system backed up and flooded our offre bathrooms and warehouse. There was 0,5"-1.o0" of sewer water that was siting sittee since the early hours of the morning.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
June 6 and Tine 7 2024 - Early Morning, Before 6Am
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side ofthis sheet, where approximate, give street names and address and measurements from landmarks:
Our Offices, bathrooms and warehouse,
What particular ACTor OMISSION do you claim causedthe injury or damage? Give names of City employees, if any. causing the injury or damage, if known:
Damase to inventory, foul Nhat DAMAGE or INJURIES do you claim resulted? Give ful extent of injuries gr damages claimed: for months until today, Probable moa in walls,
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
Give ESTIMATED AMOUNT as far asknown you claim on account of each item of prospective injury or damage, giving basis of computatio
Inventory - #22,000,00 property-??
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Expenditures made on account of accident or Injury: (Date - Item) (Amount) 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
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FOR OTHER ACCIDENTS
CURB/
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PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: gnature of Claimant or person filing on his/her behalf, givir Date:
Art Marachelian elationship to Claimar 8/23/24
IOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CA EN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV.CODE SEC.915a), STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF AN 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
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Walmart: