CLAIM FOR DAMAGES
TO PERSON OR PROPERTY
INSTRUCTIONS
1, Claims for death, injury to person or to personal property must befled not later lhan six (6) months after the occurrence. (Gov. Code Sec.9112) 2. Claims for damages to realproperty must be flled not laterthan one (1) year after the occurrence. (Gov. Code Sec.9'l '1.2)
3. Read entire claim before Illing. 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. 6. Attach separate sheels, 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
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Lily transportation
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5000 Pacific Blvd Vernon, CA
Business Address of Claimant
124 Rosemary St, Needham, MA
ity and
RESERVE FOR FILING STAMP
CLAIM No.
RECEIVEffi
r:C 0 s 2025
CI I)/ Ct TRI( DTPA RIII4 EI\j i
person
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Business Telephone Number
213-259-6530
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Give address to which you desire notices or communications to be sent regarding this claim 145 Rosemary Street Needham, MA 02494
How did DAMAGE or INJURY occur? Give full particulars.
our driver was traveling south on santa fe ave and then turn left on pacific blvd. he then was traveling west on pacfic blvd when he crossed a railroad and debris from broken street hit our landing gear of our trailer.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
09103125
Where did DAMAGE oTINJURY occur? Describefully, and locateon diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks Pacific Blvd
What particularACT oTOMISSION doyou claim causedthe injury ordamage? Givenames of Cityemployees, if any, causingthe injury or damage, if known:
Broken road debris was in the road causing our trailer landing gear to contact and caused the damage.
What DAMAGE or INJURIES do you claim resulted? Give full extent of i njuries or damages claimed WhatAMOUNTdo youclaimof each item of injury ordamage as of date of presentation of thisclaim, giving basisof computation:
$10,067.7s
Give ESTIMATED AMOUNT as faras known you claim on account basisof compulation
$10,067.75
of each item of prospective injury ordamage, giving
Damage to trailers landing gear and cross members of the trailer Were you insured at the time of the incident? lfso, provide name of insurance company, policy numbers and amount of insurance payments received:
Expenditures made on account of accident or lnjury: (Date - ltem) (Amount) Name and address of Witnesses, Doctors and Hospitals;
READCAREFULLY
For all accident claims place on following diagram names of streels, including North, East, South, and West: indicate place of accidenl by "X" and by showing house numbers or distances to street comers. lf City Vehicle was lnvolved, designate by letter'A" location of City vehicle when you flrst saw it. and by.8" location of yourself your v6hicle when you first saw Cit, vehiclei location of City vehicle at time of accident by'A-1" and location of yourself or your hicle at the time of accident by "8 1" and the point of lmpact by "X." or
NOTE:lf diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR OTHER ACCIDENTS
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I declare under nal ol u , that the fo
Typed/Printed Name:
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includi attachments is true and correct.
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Date
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NOTE:ALL CLAI MAY AE R O BE EXAMINED THEIR CLAIM U
PEN, CODE SEC.72) CLAIMS MUSTBE FILEDWITH CITY CLERK (GOVCODE SEC.915a) ST
OF A FALS IS A FELO
IF YOU ARE NOT NOTIFIED OF ANY
PAFXWAY
Signature of Claimant or Person Iiling on his/her behalf, giving rel ip to Claimant:
PRES
PROVIOES
ACTION BYTHE CI]'Y OFTHIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED a
sEc.911.6 & 912.4)
FOR AUTOMOBILE ACCIDENTS
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September 03, 2025 3 eat6ZO . I Gary Rodriguez.974181
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1 4425 Pacific Boulevard, Vernon, CA, 90058
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