CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS RECEIVED
1. Claims for death, injury to person or to personal property must be filed not later han 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) MAR 1 1 2025
3. 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. CITY CLERK DEPARTMENT
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
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)
Joshua Tadeo Gonzalez 22
Home Address of Claimant City and State THome Telephone Number Business Address of Claimant City and State Business Telephone Number Give address to which vou desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
The night of March 5,2025 between 8 and 9pm It was pouring rain and I was driving on E Washington and Soto when my tire made contact with the pothole and blew the tire on impact causing me to pull over to the Carl's jr parking lot and change the tire.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
This Damage occurred on March 05,2025 at 8pm
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:
This Damage occurred on East Washington Bld and Soto right beneath the railroad bridge coming up on the Carl's jr Intersection.
What particular ACT or OMISSION do you claim causedthe injury ordamage? Givenames of City employees, if any. causing the injury or damage, if known:
Dangerous Condition/ Negligent Act
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
This resulted in a popped front passenger tire.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
The Total was $97.46
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
When I had gone to repair the tire, the total came out to be $97.46 for the tire.
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
No
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Just replacing the tire.
Name and address of Witnesses, Doctors and Hospitals:
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. 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
I LILUL
FOR OTHER ACCIDENTS
SIDEWALK
CURB for hole
washington
CURB;
SIDEWALK
Carls dr
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:
Joshua Tadeo Gonzalez relationship to Claimant: March
10/2025
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 FILEDWITH 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) Rev. 84/16
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