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 an six (6) months after the occurrence. (Gov. Code Sec. 9112 • Claims for damages to real property must be filed not later than one (1) yea after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing.
4. ee page 2 for diagram upon which to locate place of acciden
5. his claim form must be signed on page 2 at botton
6. 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 (i natural person)
vodi chiyama 61
Home Address of blaimant ofty and State Home Telenhone 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:
or
How did DAMAGE or INJURY occur? Give full particulars.
exited the lufrwy- proceeded to Aramadu and then to
washingion Find mere were many potholes along me
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
ine damaged curred on 312125 11:40 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:
Thedamaged started on diameda and ended on washington Bwd.
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:
myhre popped from me potholes and has to call laus to come drange myhre. My car/tresare brandnew me carwas purchased 10/24).
What DAMAGE or INJURIES do you ciaim resulted? Give full extent of injuries or damages claimed:
iwas forced to puvchase a brand newtre.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
The hire corted me 4345
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
precost 4345
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, Iwas insured but did notutilize my insurance
(Amount)
Expendizures nade on account of accident or injury: (Date - ltem) F345-
Name and address of Witnesses, Doctors and Hospitals:
NIK•
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 corners. 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
washingion Bivd
FOR OTHER ACCIDENTS
PREMIER WHEELSPROTIRE
16102 S. PIONEER BLVD
NORWALK, CA 90650
03:04/2025 14:28:05
CREDIT CARD
SIDEWALK
MC SALE
CuRB) Card # XXXXCXXXXXXX3107
Chip Card: MASTERCARD
AID: A0000000041010
PARKWAY 15
SIDEWALK SEQ I:
Batch #: +37
15 INVOICE
Approval Code: 041752
Entry Method: Chip Read
Mode Issuer
I declare, under penalty of perjury, that the foregoing, including any attach SALE AMOUNT $345.00 Typed/Printed Name: Signature of Claimant or person filing on his/her benair, gıvmy Late. relationship to Claimant:
Jodi Ich yama 315/25
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINEDAS 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 8 912.4) Rey 8/4/16
Jodi Ichiyama
To: Parker, Yonnie
CC: CityClerkGroup
Re: Claim for Damages Form
Wednesday, March 5, 2025 6:59:35 PM
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Tire damage 030325.pdf
Hello Yoonie,
Thank you for your assistance on this matter.
I have attached the completed form that you forwarded to me with the information that was requested, with the receipt of the tire that I had to purchase on 3/4/25. I wanted to include that I turned east on Washington Blvd from Alameda. I have also attached a few pictures of the last pothole that I encountered. I was not able to take pictures of all the potholes that I encountered due to the traffic on the streets. If you have any questions, please feel free to contact me.
Thank you,
Jodi Ichivama
On Mon, Mar 3, 2025 at 12:30 PM Parker, Yonnie <[email protected]> wrote:
Dear Jodi,
I'm sorry to hear about the unfortunate accident to your vehicle resulting from hitting a lease tind and read the instructions on page l of thi
staced ain for and es thermon sease fine and read thinstrucion on in are al such as diagrams, photos, invoices or estimates.
Kindest regards,
Yonnie Parker, CMC | Deputy City Clerk
City Clerk Department
Desk: 323-583-8811 x 203 | [email protected]
4305 Santa Fe Avenue Vernon, CA 90058
VERNON
+
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