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 JAN 1: 20256 after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing.
4. See page 2 for diagram upon which to locate place of accident CITY CLERK DEPARTMENT
5. 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)
MARY ANN CHAVEZ-RAYA
Home Actress of Claimant City and State Home elephone 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:
How did DAMAGE or INJURY occur? Give full particulars.
I WAS TRAVELING ON ATLANTIC BLVD TO 5107 DISTRICT BLVD VERNON,CA I WAS ON THE RIGHT LANE
BEFORE REACHING DISTRICT BLVD THERE WAS A POT HOLE COULD NOT AVOID AND IT BLEW OUT MY TIRE. I DROVE MY CAR TO THE ADDRESS MENTIONED ABOVE.MY DAUGHTER CALLED AAA TO GET MY TIRED CHANGED TO SPARE.ONCE TIRE CHANGED TO SPARE I WENT TO CHECK IF MY TIRE CAN BE
PATCHED BUT IT COULDNT SO I HAD TO PURCHASING A NEW TIRE When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
FRIDAY 12/06/205 AT 11:55AM
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:
ATLANTIC BLVD/DISTRICT BLVD CITY OF 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:
DAMAGE WAS CAUSED BY A POTHOLE ON ROAD
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
RIGHT FRONT TIRE
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basisof computation:
60.00 FOR AAA AND 126.00 FOR TIRE TOTAL 185.00
Give ESTIMATED AMOUNT as farasknownyou 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:
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 comers.
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
LILL
FOR OTHER ACCIDENTS
SIDEWALK
CURB- Atlantic
DIstrict
PARKWAY
SIDEWAL
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:
MARY ANN CHAVEZ-RAYA relationship to Claimant: 12/08/25 Mary lu Chak
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 I BOVIDES 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
1/5/26, 1:12 PM IMG_8766.jpeg
ANGELS FIRE SHOP
4U50 SLAUSUL AVE
NAYWOOD, CA 9U21U
32: 404:7953
Ref I: 000i
Sale
XXXXX X1276
VISA Entry Method: Chip
Total: $ 126.00
12/05/25 13:23:13
Iny #: 000007 Appr Code: 079910
Transaction ID: 345339769931248
Apprvd: OnLine Batch#: 000177
https://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox?projector=1 1/1
manfann Chawz Ray
LOS ANGELES CA 900
9 3000.2026 :000 288
HANUKKAH
FOREVER / USA
city of veRnor
clo claums dept
4305 south santa fe Ane
VeRnon, A 90058
90058-171405