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 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 DEC SO 2025 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 CITY CLERK DEPARTMENT 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)
Manuel Reyes 25
Home Address of Claimant City and State Home Telephone Number (562) 526-5154
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:
How did DAMAGE or INJURY occur? Give full particulars.
Urove over two potholes ony telt one then noticed right away I had a flat.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
December 23° 2025 10:30pm
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:
In front of Alameda Swap Meet, 4501 S Alameda St Vernon CA 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:
Flat Tire (dandged)
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Flat Tire (damaged)
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
$176
Give ESTIMATED AMOUNT as faras known you 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:
Flora Mejia
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.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or your 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
7^T
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
X
CURB \
PARKWAY
SIDEWALK
45+h st E 46th St
Alameda Strapmeet
4)
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:
Manuel Reyes 12/30/25
Mum Ruser
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. 915). 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. 8/4/16
12/14/2025 68:34am *** INVOICE *** Page: 1/1
Premier Wheels and Pro Tires
16102 Pioneer Blvd
Norwalk, CA 90650
562-926-8472 PAID
Invoice #: 88332
Bill To:
PRO WALK IN
NORWALK, CA 90650
BUSINESS: 562-404-8558
Item # Size Description SImn/Tech Qty FET Parts Labor Extended 15579290000 235/40R18 CONTIPROCONTACT RX [BW] RG / 1 0.00 120.69 0.00 120.69 [91] [W] [SL]
BAL1720 BAL1720 TIRE MOUNTING & RG / 1 0.00 0.00 40.00 40.00
BALANCING
TDF TIRE DISPOSAL FEE RG / 1 0.00 0.00 1.50 1.50
Comments:
Cash: 0.00 Name Acct Auth Amount
Check: 0.00 Parts: 120.69
Credit Card: 176.61 On Acct: 0.00 Debit 176.61 Labor: 41.50 Subtotal: 162.19
Amount Tendered: $176.61
Total: - $176.61 Tire Tax: 1.75
Change: $0.00 Sales Tax: 12.67
Total: $176.61
Customer Authorization:
PREMIER INHEEL PROTIRE
16102 S. PIONEER BLVD
NORWALK, CA 90650
12/24-2025 06:34:37
DEBIT CARD
DEBIT SALE
Card : XXXXXXXXXXxX1581
Network. MAESTRO
Chip Card: VS COMMON
AID: A0000000980840
SEQ #: 1
Batch #: 685
INVCICE 1
Approval Code: 001187
Enty Method: Contactless
Mode: Issuer - PIN Verified
SALE AMOUNT $176.61
CUSTOMER COPY