CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
1. Claims for death, injury to person or to personal property must be filed not later VERNON 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) 2026 APR - 9 A 10: 28 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. CITY CLERK DEPARTMENT 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)
Marvin Aquilar Delgado 37
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.
My Wehicle was legally Parked on the street While city personnel were Pertorming graffity Paint overspray on to the body. Windows, hook PoorDuring the process trim of mu
Vehicle causing Permanent Spotting and damage to Finish.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
April 6,2026 approximate between 7 and 10 am
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:
East side of E sand or especifically Where Lompany
Angels Craff Is locate
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:
Negligence during graffity removal operations city crew, failed to use Protective barriers or lovers, allowing Pant overspray to drift and damage my Vehicle.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Extensive faint overspray covering the vehicle factory paint window Loof, Doors and trim of my vehille. The particle have bonded to the Clea Loat complete Professional restoration.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$11,784.71
Based on a formol repair estimate forma Certified collision and restoration center Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury ordamage, giving basis of computation: $ 11,784.71
I reserve the right to amend this amount if additional hidden damaces ore discovered during the restoration process
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments reccived: Yes. Name: Progressive, Policy number:
$0.00 Payments received
Expenditures made on account of accident or Injury: (Date - Item) 04/06/2026 Professional outo Paint restoration Stimate $11,784.71 Name and address of Witnesses, Doctors and Hospitals:
City of vernon Public Works maintenance Crewon duty
at E 52nd Dr on 04/06/2026.
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
FOR OTHER ACCIDENTS
///
SIDEWALI
Wall that was cleaned of graffit Helio trope Ave.
X
E 52nd Dr
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: 04/09/2026
Marvin Aguilar Delyado
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 PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ~An-
Santa Fe Collision Center Inc. Workfile ID: dd71df3c
13659 Pumice Street, Santa Fe Springs, CA 90670
Phone: (562) 677-5515
Preliminary Estimate
Customer: Na, Marvin
Written By: John Virabian
Insured: Na, Marvin Policy #: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
Na, Marvin Santa Fe Collision Center Inc.
13659 Pumice Street
Santa Fe Springs, CA 90670
Repair Facility
(562) 677-5515 Business
VEHICLE
2025 NISS Kicks SR FWD 4D UTV 4-2.OL Gasoline Sequential MPI VIN: Interior Color: Mileage In: Vehicle Out:
License: Exterior Color: Mileage Out:
State: CA Production Date: Condition: Job#:
TRANSMISSION Tilt Wheel FM Radio Xenon or L.E.D. Headlamps Automatic Transmission Cruise Control Stereo Blind Spot Detection POWER Rear Defogger Search/Seek Lane Departure Warning
Power Steering Keyless Entry Auxiliary Audio Connection SEATS Power Brakes Alarm Satellite Radio Cloth Seats
Power Windows Message Center SAFETY Bucket Seats
Power Locks Steering Wheel Touch Controls Drivers Side Air Bag WHEELS Power Mirrors Rear Window Wiper Passenger Air Bag Aluminum/Alloy Wheels DECOR Telescopic Wheel Anti-Lock Brakes (4) PAINT
Dual Mirrors Climate Control 4 Wheel Disc Brakes Clear Coat Paint Privacy Glass Backup Camera Traction Control OTHER
Console/Storage Parking Sensors Stability Control Rear Spoiler Overhead Console Surround View Camera Front Side Impact Air Bags Signal Integrated Mirrors CONVENIENCE Intelligent Cruise Head/Curtain Air Bags
Air Conditioning RADIO Rear Side Impact Air Bags
Intermittent Wipers AM Radio Hands Free Device
4/7/2026 11:23:32 AM 472432 Page 1
Preliminary Estimate
Customer: Na, Marvin
2025 NISS Kicks SR FWD 4D UTV 4-2.0L Gasoline Sequential MPI Line Oper Description Part Number Qty Extended Labor Paint Price $
1 # textures parts not able to 1
polish/buff
2 # detail/polish buff entire car 1 1,000.00
exterior vehicle has overspray
FENDER
4 Repl RT Wheel opng midg 638107LGOA 1 410.62 0.4
5 Repl LT Wheel opng midg 638117LGOA 1 387.38 0.4
6 ROOF
Repl RT Roof rack G38207LGMA 1 893.25 0.4
8 Repl LT Roof rack G38207LGMA 1 893.25 0.4
9 FRONT DOOR
Repl RT Body side midg SV, SR 808707LGOA 1 987.71 0.4
11 Repl RT Belt molding 808207LF0A 1 215.95 0.2
12 Repl RT Mirror assy w/o heated SR 963017LF6A 1 843.80 0.4 13 Repl RT Corner cover SR 802907LF0B 1 44.91 0.1
14 Repl LT Corner cover SR 802917LF0B 1 44.91 0.1
15 Repl LT Body side midg SV, SR 808717LGOA 987.71 0.4
16 Repl LT Mirror assy w/o heated SR 963027LF6A 849.22 0.4 17 Repl LT Handle, outside SV, SR gun 806D17LF3A 1 134.18 0.4 0.5 metallic
18 Add for Clear Coat 0.1
19 Repl RT Handle, outside SV, SR gun 826D07LF3A 1 134.18 0.4 0.5 metallic
20 Overlap Minor Panel -0.2
21 Add for Clear Coat 0.1
22 REAR DOOR
23 Repl RT Body side midg SV, SR 828707LG0A 1 613.93 0.4 24 Repl RT Belt molding 828207LFOA 182.36 0.2
25 Repl RT Upper molding 822827LF0A 107.62 0.2
26 Repl LT Body side midg SV, SR 828717LG0A 613.93 0.4
27 Repl LT Upper molding 822837LF0A 107.62 0.2
28 Repl LT Handle, outside SV, SR cloud 826D37LF0A 1 67.24 0.4 0.5 white
29 Overlap Minor Panel -0.2
30 Add for Clear Coat 0.1
31 Repl RT Handle, outside SV, SR cloud 826D27LF0A 1 67.24 0.4 0.5 white
32 Overlap Minor Panel -0.2
33 Add for Clear Coat 0.1
34 QUARTER PANEL
35 Kepi kI wheei opng midg 93828/LGUA 1 20/.04 0.4
36 Repl LT Wheel opng mldg 938297LGOA 1 207.04 0.4
SUBTOTALS L0,001.05 7.4 1.8
4/7/2026 11:23:32 AM 472432 Page 2
Preliminary Estimate
Customer: Na, Marvin
2025 NISS Kicks SR FWD 4D UTV 4-2.0L Gasoline Sequential MPI
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 10,001.09
Body Labor 7.4 hrs _@ $ 70.00/hr 518.00
Paint Labor 1.8 hrs @ $ 70.00 /hr 126.00
Paint Supplies 1.8 hrs @ $ 45.00 /hr
Subtotal 10,726.09
Sales Tax $ 10,082.09 @ 10.5000% 1,058.62
Grand Total 11,784.71
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 11,784.71
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM. ANY PERSON
WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT INFORMATION TO OBTAIN OR AMEND INSURANCE
COVERAGE OR TO MAKE A CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
THIS ESTIMATE IS FOR REPAIRS TO MEET VEHICLE MANUFACTURER AND INDUSTRY STANDARDS. AS THE
CUSTOMER, IT IS YOUR RESPONSIBILITY TO CONTACT THE THIRD-PARTY PAYOR FOR PAYMENT OF THE REPAIRS YOU HAVE AUTHORIZED.
THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY
BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:
MOTOR ABBREVIATIONS/SYMBOLS: D-DISCONTINUED PART,
A=APPROXIMATE PRICE. LABOR TYPES: B=BODY LABOR, D=DIAGNOSTIC, E=ELECTRICAL, F=FRAME, G=GLASS, M=MECHANICAL, P=PAINT LABOR, S=STRUCTURAL, T=TAXED MISCELLANEOUS, X=NON TAXED
MISCELLANEOUS. CCC ONE: ADJ=ADJACENT, ALGN=ALIGN,
A/M=AFTERMARKET, BLND=BLEND, CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT,
EST=ESTIMATE, EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED, MISC=MISCELLANEOUS, NAGS=NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ=NON ADJACENT, O/H=OVERHAUL,
OP=OPERATION, NO=LINE NUMBER, QTY=QUANTITY,
RECOND=RECONDITION, REFN=REFINISH, REPL=REPLACE, R&I=REMOVE AND INSTALL, R&R=REMOVE AND REPLACE, RPR=REPAIR, RT=RIGHT, SECT=SECTION, SUBL=SUBLET, LT=LEFT, W/O=WITHOUT, W/_=WITH/_ SYMBOLS: #=MANUAL LINE ENTRY, *=OTHER [IE..MOTORS DATABASE INFORMATION WAS CHANGED], **=DATABASE LINE WITH AFTERMARKET, N=NOTES ATTACHED TO LINE. OPT OEM=ORIGINAL EQUIPMENT
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT.
4/7/2026 11:23:32 AM 472432 Page 3
APRIL 9, 2026
TO THE CITY CKERK, CITY OF VERNON
Dear,
I am writing to formally follow up on claim previously filed regarding the paint damage caused to my vehicle during city maintenance activities. My objective is to express my full cooperation in resolving this matter in an expeditious and definitive manner.
I am re-attaching evidence of the incident to facilitate a prompt review. I request that the compensation process be prioritized to prevent further inconvenience, and | look forward to your response.
Sincerely,
Marvin Aguilar Delgado.
E-mail:
KICKE