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) MAY 2 1 2025 Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident CITY CLERK'S OFFICE This claim form must be signed on page 2 at bottom.
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
Andrea somet pay caimant (i naturat person)
Home Address of Claimant Citv 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:
huge pothole exiting freeway
How did DAMAGE or INJURY occur? Give full particulars.
5/18/25
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Exit S. Atlantic Riva
Where did DAMAGE orINJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Nhat particular ACT or OMISSION do you claim causedthe injury ordamage? Give names of City employees, if any ausing the injury or damage, if known
2left tires blown out
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
$200.00
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
Give ESTIMATED AMOUNT as far as knownyou claim on account of each item of prospective injury or damage, giving basis of computation:
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 corners.
NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
Allantic Blvd
7Л)
FOR OTHER ACCIDENTS
CURB/
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:
relationship to Claimant:
Andrea Gomez ind 5|21/25
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 & 912.4) Angel's Tires Shop Inc. FIGELA
INVOICE
Work: (323) 404-7953
TRES
Phone: (323) 404-7953 Fax: (000) 000-0000
4050 Slau
Mon-Sat: 7am - 7pm DATE 5/18/2025
IN Sun: 7am - 6pm New/used tires sales, tire
epal, wneel repair, Cu
Address: 4050 Slauson Ave Maywood, CA 90270 alancing. TPMS servic Email: [email protected] ГОУС
Website: www.angelstires.com
C колено тие?
All sales are final. Limited warranty on used tires, refer to нонет с напкоон
PAID
MAY 1 8 2025
PAID
Point of Contact:
MAY 1 8 1925
hite corolla 2018
AMOUNT
SERVICES PERFORMED
Recommendations: () Alignment () Rotation AT 5,000 or 6 mths whatever comes first ( ) Bad shocks need scustomer Aware.
Bad studs & Lug nuts This is all customer's resposibility replacement ( damage rms
To All customers any Manufactures guarantee Such as limited miles or standard warranty are strictly manufactures warranties Manufactures limited miles,defects warranty from Manufacturer only RECEIPT MUST BE PRESENT AT ALL TIMES PLEASE.
Alignment is always recomendeed when adding new tires to hicles, to protect custmer investment
SUBTOTAL
30,000) (35,000 )(40,000) (4 0) 50,000) (55,000) (60,000) (65,000) 0.000%
TAX RATE
70,000) (75,000) (80,000) (90.0 d warranty only. All manufacture warranties are limited on all new tires when purchasing a new tire you are agreeing to all terms and conditions. AMOUNT 2 100.00 $200.00
215/45/17 BlacHwlawk 480 AAA 91W XL
PAID
milea 101,479
MAY 1 8 2025
above and be this invisige
have read and agreed accopted ait Angels Tires terms 200.00 • Terms & conditions All sales are final upon acceptance and inspection of goods by customer. SUBTOTAL TAX RATE 0.000%
All tires are suject to manufactures limited warranties suchas miles, factory defects& disparfection Road hazzard, aggressive driving or distracted driving is not Angel Tires respossibility TOTAL SERVICES $
This is fully the responsibilly of the driver or the owner of the vihecis.
TOTAL PARTS $ 200.00
Returns: All returns are suject to deep inspection of the products, a 30% return fee, re-isntallatio
TOTAL TAX
if units are found in new saleable condition with no wear and tear damages but still the 30% TOTAL 200.00
of any installation erfors whithin 7 day period excludes new nails or other road hazard incidents that did not existed at the time of the Angel's Tires Shop inc
installation. Angel's tires shop inc. Strongly recomends customers to have theire vehicles aligt Sign here X to protect their investments.All guarantees Such as limited miles, standard warranty are strict manufactures guaranties math Hot