CLAIM FOR DAMAGES
TO PERSON OR PROPERTY
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^ 91 12) 2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.91 1.2) 3. Read entire claim before filing. 4. See page 2 for diagram upon which to locate place of accident 5. This claim form must be signed on page 2 at bottom. 5. Attach separate sheets, if necessary, to give full details. SIGN EACH SH 7. Claim must be filed with City Clerk. (Gov.Code Sec. 915a) TO: CITY OF VERNON CITY N
LOS ANGELES COUNTY METROPOLITAN TRANSPORTATION AUTHORITY me rESS
N/A
Business Address of laimant City and State Bu
One Gateway Plaza, Los Angeles, CA 90012
Give address to
Robert T. Mackey
RESERVE FOR FILING STAMP
cLArM NoHMZ__ \r\ VHHNON
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CITY CLERK DEPARTMENT
n person
one
N/A
ness one Number
(800) 464-2111
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ome
N/A
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which you, desrre notices or communications to be sent regarding this claim , Esq. rmackey@veatchfl rm.com ;sangulo@veatchfi rm.com VEATCH CARLSON, LLP., 1055 wlshire Boulevard, 11th Floor, Los Angetes, cA 90017 (213],404-1119
How. did DAI\4AGE lnrs ts a clarm lor eql or INJURY occur? Give full oarticulars. urtable rndemntty, contribution ahd declaratory relief. Plaintiff, Lucia Becerriltripped and fell on an exposed bolt in the sidewalk in front of 4840 Pacific Blvd, Vernon, cA. Plaintiff Becerrilsued the city of Vernon, County of LA, LACMTA, City of Huntington Park, LA Times Communications, LLC., Romero's Engineering, lnc., and Ameri can Turn-Key Fabricators alleging dangerous condition of public property. The lawsuit is captioned: Lucia Becerril v. City of Vernon, et al., LASC Case No. 26STCV16575. lnvestigation shows that LACMTA had no interest or role in the subject sidewalk which LACMTA is advised and believes was owned, maintained, repaired and the responsibility of the City of Vernon.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.
On October 24,2025 at approximately 4:46p.m.
Wheredid oTINJURY occur? Describefully, and locateon diagrarn on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
On the sidewalk in front of 4840 Pacific Blvd., Vernon, CA 90058.
What particularACT or OMISSION doyou clai
causing the injury or damage, if known:
mcausedthe injury ordamage? Givenamesof Cityemployees, if any, The City of Vernon owned, maintained, repaired, controlled and was responsible for the subject sidewalk and failed to remedy the alleged dangerous condition and/or failed to warn of it despite actual and/or constructive notice of the alleged condition a sufficient time prior to Plaintiffs alleged trip and fall to have done so. ldentities of City employees/vendors are unknown at this time.
What DAMAGE or I NJURIES do you claim resulted? Give full extent of injuries or damages claimed:
lndemnity and Contribution; LACMTA's attorney's fees and cost of defense for the lawsuit and any judgment/award.
WhatAMOUNTdo you claim of
computation:
each item of inj ury or damage as of date of presentation of th is claim, givin g basis of At this time, the amount cannot be determined until the case is over and depends on whether it was settled or tried Give ESTIMATEDAMOUNT
basisof computation.
as faras known you claim on account of each item of prospective injury ordamage, giving At this time, the amount cannot be determined until the case is over and depends on whether it was settled or tried Were you insured at the time of the incident? lf so, provide name of insurance company, policy numbers and amount of insurance payments received:
N/A; however, as for the subject incident, LACMTA is self-insured up to 12.5 million.
Expenditures made on account of accident or lnjury: (Date - ltem) TBD when the case is concluded.
(Amount)
Name and address of Witnesses, Doctors and Hospitals:
N/A as to LACMTA. Plaintiff Lucia Becerril can be contacted through her attorney of record Frank Perez, Esq., cio Perez & Perez, APC 1 150 S. Olive Street, Ste 600, Los Angeles, CA 90015 (213)745-6300
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. lf City.Vehicle was lnv_olved, d.=eignate. by letter'A" location of City vehicle when you first saw it, and by "8" location of yourself or youi' vehicle when you first salv C_ity vehicle; location of City vehicle at time of accident by 'A-1 " and loc-ation of yourself 'or your
vehicle at the time of accident by"8 1" and the point of lmpact by "X." NOTE:lf diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTONTOBILE ACCIDENTS
7Affi
*T'BF
I declare under of
Typed/Printed Name:
Robert T. Mackey, Esq.
PACIFIC BOULEVARD
u that the
ndc ai
BOLT
includin attachm is true and correct.
Date
7t24t2026
OF A FALSE CLAIM IS A
Damages against the City of
4840 Pacific Blvd.
nl rm see
on his/her behalf, giving
relationship to Claimant:
gnature or person
PEN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (qovcoDF 9Eq: el,s?)r9T{IE LAW PRoVIDES rHAr lF YoU ARE NOr NorlFlED oF ANY .@"