CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
12/30/2025 Received
INSTRUCTIONS City Clerk Department
1. Claims for death, injury to person or to personal property must be filed not later Y. Parker 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)
3. Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom.
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 (If natural person)
Annette Davis
Home Address of Claimant City and State Home Telephone Number 323-633-7051
Business Address of Claimant City and State Business Telephone Number Not Applicable
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
I was driving West down Bandini Blvd going right before Pennington Way and heard a sound my right front tire on the passenger side burst. My tire light immediate came on. It was a large pothole that caused the damage.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Monday, December 01, 2025. Between 5:30 a.m. to 6:00 a.m.
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 happened between Yeager and Pennington Way. The pothole was right before Pennington Way, the left lane in the City of Vernon. The City of Vernon sign was on the right side.
What particular ACTor OMISSION do you claim causedthe injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
The pothole in the street that caused the tire damage.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Tire busted due to the pothole, and I had to purchase a new tire.
Attachment: You will find picture of pothole, tire damaged and receipt of purchase for new tire.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$240.00
basis of computation: Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving $240.00
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
I am insured but this was no auto accident. So, it is not required and does not pertain to this Expenditures made on account of accident or Injury: (Date - Item) (Amount) 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 plac of accident by "X" and by showing house numbers or distances to street corners If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yoursell venice the we derby end the pito ma by eat time of accident by A-1" and location of yourself or your 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
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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 Annette Davis Date:
relationship To Claimant
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS YO THEIR CLAIM Y 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 ANY DER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL 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
Name
BLESS TIRES & WHEELS
WHEELS & TIRES
Address
Lic. #AC 252286
13143.Rosecrans Ave., Santa Fe Springs, CA 90670 State Zip City
Tel: (562) 404-6604 / Fax: (562) 623-0556
Date Mileage Home Phone
•/20
Year / Make / Model Bus. Phone
VIN Lic. # Written By Cel. Phone
DESCRIPTION OF WORK TOTAL
LIS
Origina: Authorized Date & Time
Estimate By TOTAL
LABOR
Note: Warranty Hot Valid Without This Receipt.
Wheel cig ements only 30 drys werent. Wot erroaty i rebides have been lomer or bare been lifted or asy modification on the suspension. TOTAL Its custemer responsibility to chect their tire pressure ond do their tire rotation. For tires and wheels brought back for womanty Bless Tires will PARTS sead it out to the manufadure and they will determine if it is or not o deled meanwhile its customer responsibility to provide its spare for time that this will tele. When velices are brought for any womanty repairs veticies needs to drop off ond left for inspection and wait for Bless Tires lo conto the customer to discess ey issues on the vetice. Warmanty valid only it stated on the invalice. Mo cash refunds, credit, ATMs. Depesit TIRE for lywys and special orders are noo relandeble. All sales are finol so exchonges on any perchese speciallyon tires ond wheels. Once astomer FEE chooses e style of tires end beels connot be exchanged or return. No womanty on used tires. No gorastio en lastes usados. By muaing yar tires lom or without eir you will loose voranty estonticaliy. I's customer responsibility to check the tightness of their wheels ofter 10 or 25 miles at driving and every 50 miles there after antil legnuts bold their torque. 30 Days chrome wheels worsty. No rood hazards woront All nee DISPOSAL wheels ond tires are cover by manufochure defeds onlyko accidental coverage, womanty will be automstically voided when vehides ore taken FEE to toother mechenic or someone else has pioce hones on vehicle. We are net responsible for items left on vehicles ond customers who leave there stack wheels ond tires. Mo warranty on pointing wheels, Drilling. Bless Tires is not resposible for wheel stuts ling nuts woren out ond get SUBLET Broken of time of instollotion. Warmaty valid only when stoted on invoices. Agreement by signing below ucceptance of obove perlormed os REPAIR being satisfectory and the all job done hes been left in good condition Blees Tires is not respoesible for any towing charges on any vehicle thet hes been repair on our lecations, crstomers are responsible for any towing fees. We are not responsible for any aheels or tires left in our she p after 3 days of porchose. TAX
STORAGE VEHICLES $55.00 STORAGE CHARGE PER DAY AFTER 3 DAYS FROM PROMISED DAY ITEM WILL BE SOLD 30 DAYS THEREAFTER
TOTAL
SIGNED X