CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
RECEIVED
INSTRUCTIONS
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) JAN 22 2026 3:30 up
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2) CITY CLERK DEPARTMENT
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.
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)
Jacob A. Cortez 19
Home Address of Claimant City 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:
How did DAMAGE or INJURY occur? Give full particulars.
Iwas driving on s. Alameda passing Washington St. when I landed on a pothole that my tire popped. Inad to drive to a safe area to check on the tire. It had damaged my tire by making a hole and unsafe to drive.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Monday December 29.2025 @ l:48 p.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:
Driving:. Alameda passing Washington there were many potholes that What particular ACT or OMISSION do you claim causedthe injury or damage? Givenames of City employees, if any, causing the injury or damage, if known:
Pot holes after rain damaged the orphalt it loosened up that created a deep pothole.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
It damoged my tire that I had to purchare a new tire so I can transport myself to work.
What AMOUNT do you claim of each item of injury or damage as of date of presentation ofthis claim, giving basisof computation: $ 138.44
Give ESTIMATED AMOUNT as farasknown you claim on account of each item of prospective injury or damage, giving basisot computation: $ 138.94
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
South * Alameda f 4
7^1
FOR OTHER ACCIDENTS
SIDEWALK
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:
Jacob Cortez/ Olivia Esparza Olivia espanze 1|20/24
VOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CA EN. CODE SEC. 72). CLAIMS MUST BE FILEDWITH CITY CLERK (GOV.CODE SEC.915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF AN' 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)
FAIRMOUNT
TIRE & RUBBER INC GOOD YEAR MICHELIN TOVO WHankOOl
No Hidden Charges I Since 1958 FORTUNI
LauFenn •OTAN! REMINGTON TIRES
600 West Slauson Avenue | Los Angeles, CA 90044 TIRE
Phone: (323) 750-8676 | Fax: (323) 750-2981
DATE CUST # ORDER # PG INVOICE #
www.fairmounttire.com
Monday - Friday 7:30am - 5:00pm 12/30/25 20002 182963 2-993781 yelp.% Saturday 7:30am - 4:00pm
BAR #ARD00305563
CUSTOMER INFORMATION: SHIPPING INFORMATION:
JACOB CORTEZ
P.O. # MAIN PHONE OTHER PHONE SHIP VIA
Cash
100
ITEM NUMBER DESCRIPTION QTY SHIPPED UNIT TOTAL
1016111 225/40R18 88W HANK VENTUS H452 DD 1 1 0.00 125.00 125.00 TS FAIRMOUNT TREADSHIELD BASIC 1 0.00 0.00
*FREE MOUNTING & FREE BALANCE
*FREE FLAT REPAIR
?
DISP CALIFORNIA NEW TIRE FEE 1 1 1.75 1.75
FAIR OUNT
PUBLIC
TORQUE SPECS
TECHNICIAN
LINE RF LR RR
NOTES SubTot Parts: 126.75
nana $1.06 Tax 9.750%: 12.19
READ IMPORTANT INFORMATION ON REVERSE SIDE. PLEASE BE ADVISED THAT FAIRMOUNT TIRE & RUBBER, INC. IS NOT RESPONSIBLE FOR CUSTOMER'S TIRES, WHEELS, PARTS, ETC. LEFT BEHIND FOR MORE THAN TWO (R) BAYS. SERVICE CHARGE: Interest shall be charged at the rate of 1.5% per month on all accounts over 30 days. ACCOUNT CHARGES ARE DUE AND PAYABLE. WARRANTIES: The only warranties respecting the goods sold herein shall be those warranties made with respect to any such goods by the manufacturer of such goods. Fairmount Tire & Rubber, Inc. makes no express or implied warranty of any kind with respect to the usage, performance or merchantability of such goods or their fitness for a particular purpose. INSPECTION: Customer shall inspect all goods immediately upon receipt thereof. All claims for shortages, Inv Total 138.94
defective merchandise, or improper mountings, if any, must be made, in writing, within 5 calendar days of actual receipt of goods. THIS TRANSAC- TION IS SUBJECT TO AND INCLUDES ALL OF THE TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS DOCUMENT.
SIGNATURE