HomeMy WebLinkAbout03 CONS OF CLAIMS, J BELL, ET AL 05-20-08 AGENDA REPORT
MEETING DATE: May 20, 2008
TO: William A. Huston, City Manager
FROM: Ronald A. Nault, Finance Director
SUBJECT: CONSIDERATION OF CLAIMS OF JENNIFER BELL, ET AL.
SUMMARY:
The Attorney for the Claimants reported that several police agencies had raided a house they were
in and taken the individuals from bed, handcuffing and detaining them without an arrest. He stated
the Claimants were denied legal representation, were not Mirandized, and were denied medical
assistance in some instances. The Claims are for $100,000 in property damage to the residence
and an amount for personal injury to be determined at trial.
RECOMMENDATION:
That the City Council deny the Claims as listed below and direct Staff to send notice thereof to the
Claimants' Attorney.
Claim No. 08-07 Lorraine Colarossi
Claim No. 08-08 Robert Green
Claim No. 08-09 Jennifer Bell
Claim No. 08-10 LeRoy Guillory
Claim No. 08-11 Carl Bergeman
Claim No. 08-12 Carmine Colarossi
Claim No. 08-13 Anthony Michael Bergeman
Claim No. 08-14 Scott Deere, Sr.
Claim No. 08-17 Altan Aksu
Claim No. 08-18 Darren Johnson
Claim No. 08-19 David Ryder
Claim No. 08-22 John D'Agostino
Claim No. 08-23 Kathleen D'Agostino
FISCAL IMPACT:
None.
DISCUSSION:
The three Tustin Police Officers were part of a team assisting the Orange County Sheriffs
Department (SWAT) in serving a high risk search warrant based on probable cause. No arrests
were made by the City of Tustin personnel.
The City's Claims Administrator has found no liability as to the City of Tustin for the damages
reported by the Claimants' Attorney. There is no indication in the police reports of force or any
action taken by the agencies involved which would result in injury to the individuals and property at
the residence.
Staff recommends denial of these claims.
RonaId A. Nault
Finance Director
ATTACHMENTS:
Claim No. 08-07
Claim No. 08-08
Claim No. 08-09
Claim No. 08-10
Claim No. 08-11
Claim No. 08-12
Claim No. 08-13
Claim No. 08-14
Claim No. 08-17
Claim No. 08-18
Claim No. 08-19
Claim No. 08-22
Claim No. 08-23
ConsiderationOfClaimsOfJennifer8ell, EtAI. doc
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property)
CITY
Received Via:
^ U.S. Mail
^ Inter-Office Mail
^ Over the Counter
CITY of TUSTIN
Time Stamp:
2008 APR - 7 P l:33
Claim No:
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the Citv of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the Claimant:
Name of Claimant:
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest. Individuals were denied legal representations, were not
Mlrandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86. )
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1"and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
SIDEWALK
CURB
PARKWAY
SIDEWALK
7
CURB
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date: 3/26/08
Page 3 of 4
IF LATE CLAIM: COMPLETE ITEMS 1- 9 AND THIS APPLICATION.
SIGN BOTH FORMS.
APPLICATION FOR LEAVE TO PRESENT A
LATE CLAIM TO THE CITY OF TUSTIN
The undersigned hereby applies for leave to present a late claim to the City of Tustin. This application is being made
within a reasonable time, not exceeding one (1) year, after the accrual of the cause of action. Under some circumstances,
leave to present a late claim will be granted (Government Code § 911.6). The reason for delay in presenting the claim is:
Date Signature of Claimant
Revised 12/2004
Page 4 of 4
•
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property) -,
Received Via: Time Stamp:
^ U.S. Mail '~`~n h;~,!? f `~ /~ ~: ~ ~
^ Inter-Office Mail
^ Over the Counter Claim No: D ~ - D ~
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the Claimant:
Name of Claimant: Jennifer Bell
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest. Individuals were denied legal representations, were not
Mlrandized, and in some instances denied medical assistance.
Page 1 of 4
•
The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do .not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach, any medical bills or repcrts or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration: __
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
•
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of .City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
~/
CURB
%/
SIDEWALK
SIDEWALK
CURB
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date:
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property) CITY Q ~ T U S T I Pd
Received Via: Time Stamp:
^ U.S. Mail ~Q08 ~;r,~; ! q A S~ 5 ~
^ Inter-Office Mail
^ Over the Counter Claim No: Dd°-/~
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the Claimant:
Name of Ciaimant: Anthony Michael Bergeman
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied me Ica assts ance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest Individuals were dented legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bel, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
~/
CURB
%/
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
SIDEWALK
SIDEWALK
CURB
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature
Date: 3-3-08
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property) ~ f .~ ~, ~ ~ ~ ~ S ~ I ~~
Received Via: Time Stamp:
^ U.S. Mail ~ ~~ Via: ~,n ~ o t~ ~~ S U
^ Inter-Office Mail
^ Over the Counter Claim No: O ~ --l !
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the Claimant:
Name of Claimant: Carl Bergeman
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest Individuals were denied legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or foss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bel, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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 CitylAgency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
~/
CURB
CURB
PARKWAY
SIDEWALK
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
SIDEWALK
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date:
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property)
Received Via: Time Stamp:
^ U.S. Mail
^ Inter-Office Mail
^ Over the Counter Claim No: 08-12
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the Claimant:
Name of Claimant: Carmine COlarOSSI
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house dragged individuals from bed, handcuffed and detained,
individuals without an arrest Individuals were denied legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department _
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86. )
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bel, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
8. If applicable, please attach any medical bills or reports or similar documents supporting your claim.
If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
_~/
CURB
%/
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1"and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
SIDEWALK
SIDEWALK
CURB -1,
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date: 3/12/08
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property)
Received Via: Time Stamp:
U.S. Mail
^ Inter-Office Mail
^ Over the Counter Claim No: 08-07
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the..Claimant:
Name of Claimant: LOrralne COIarOSSI
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest. Individuals were denied legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86. )
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bel, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8.If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year.
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.,
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
CURB
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
SIDEWALK
PARKWAY
SIDEWALK
CURB ~,
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date: 3/12/08
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN OF -~~ST1~~
(For Damages to Person or Personal Property) C~TY
Received Via:
~.U.S. Mail
^ Inter-Office Mail
^ Over the Counter Claim No:
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
Name and Post Office address of the Claimant:
Name of Claimant: John D'Agostino
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house dragged individuals from bed, handcuffed and detained,
individuals without an arrest Individuals were denied legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
~/
CURB
%/
SIDEWALK
SIDEWALK
CURB ~,
Page 3 of 4
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property)
Received Via: Time Stamp:
U.S. Mail
Inter-Office Mail
^ Over the Counter Claim No: 08-23
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the Claimant:
Name of Claimant: Kathleen D'Agostino
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3: The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest. Individuals were denied legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or toss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, Exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
!f applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
_~/
CURB
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1"and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
SIDEWALK
CURB
%/
SIDEWALK
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date: 4/17/08
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property) CITY O F T U S T I N
Received Via:
^ U.S. Mail
^ Inter-Office Mail
^ Over the Counter
Time Stamp:
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
Name and Post Office address of the Claimant:
Name of Claimant: Scott Deere, Sr.
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest Individuals were denied legal representations, were not
Mirandized, and in some instances denied. medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1"and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
~/
CURB
%/
SIDEWALK
SIDEWALK
CURB ~,
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date: 3/3/08
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property)
Received Via:
^ U.S. Mail
^ Inter-Office Mail
^ Over the Counter
Time Stamp:
Claim No:
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf {Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
Name and Post Office address of the Claimant:
Name of Claimant: Robert Green
Home Address: Claimantcan be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
_ Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest Individuals were dented legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recover; sought, exc!usi~~e of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86. )
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
CURB
SIDEWALK
PARKWAY
SIDEWALK
CURB -
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date: 3/12/08
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
- For Dama es to Person or Personal Property)
Received Via: Time Stamp:
^ U.S. Mail
^ Inter-Office Mail
^ Over the Counter
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the City of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
1. Name and Post Office address of the Claimant:
Name of Claimant: LeRoy GuillOry
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest Individuals were denied legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86. )
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bel, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
~/
CURB
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
SIDEWALK
CURB
PARKWAY
SIDEWALK
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature: ~ ~,,`~~/ v~J'
Date:
Page 3 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property) C 1 T~ 0 F T U S T I I"d
Received Via: Time Stamp:
^ u.s. Mail Z~~g ppR _ 1 p I : 3 3
^ Inter-Office Mail p~
^ Over the Counter Claim No: Li ~~~ Q
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the Citv of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Government Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
Name and Post Office address of the Claimant:
Name of Claimant: ~~U~~ ~Cn-{T(St~rJ
Home Address: Claimant can be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dra ed individuals from bed, handcuffed and detained,
Individuals without an arrest. Individuals were denied le al representations, were not
Mlrandlzed, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86. )
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
/f applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
SIDEWALK
CURB
PARKWAY
SIDEWALK
7
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1"and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
CURB
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date:
Page 3 of 4
IF LATE CLAIM: COMPLETE ITEMS 1- 9 AND THIS APPLICATION.
SIGN BOTH FORMS.
APPLICATION FOR LEAVE TO PRESENT A
LATE CLAIM TO THE CITY OF TUSTIN
The undersigned hereby applies for leave to present a late claim to the City of Tustin. This application is being made
within a reasonable time, not exceeding one (1) year, after the accrual of the cause of action. Under some circumstances,
leave to present a late claim will be granted (Government Code § 911.6). The reason for delay in presenting the claim is:
Date Signature of Claimant
Revised 12/2004
Page 4 of 4
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property)
CITY OF TUSTIf•~
Received Via: Time Stamp:
^ U.S. Mail
^ Inter-Office Mail jppa ~pR - l P 1 ~ 3 3
^ Over the Counter Claim No: CU ~~~
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the Citv of Tustin, not another public entity.
C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the occurrence
(Govemment Code § 911.2).
D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2).
E. If additional space is needed to provide your information, please attach sheets, identifying the paragraph(s) being answered.
F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall provide the information shown below and must be signed by the claimant or a person on
his behalf (Government Code § 910.2).
G. This form is for the convenience of those desiring to present claims against the city. Claimant is advised to consult a private
attorney if legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin,
California 92780.
Name and Post Office address of the Claimant:
Name of Claimant ~iNl1~ ~(~~`~'~
Home Address: Claimantcan be contacted through his attorney:
Richard Quintilone, Esq. Quintilone & Associates
Lake Forest, Ca 92630, 949-458-9675, Fax:949-458-9679
Home Telephone: Work Telephone:
2. Post Office address to which the person presenting the claim desires notices to be sent:
(If different from above)
Name of Addressee: Telephone:
Post Office Address:
3. The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: 10.28.07 Time of Occurrence: Approx: 0300 hour through 1500 hour
Location: 2606 Vista Panorama, Santa Ana, Ca 92705
Circumstances giving rise to this claim:
Several police agencies raided a house, dragged individuals
from bed, handcuffed and detained, individuals without an arrest. Individuals were denied
legal representations, were not Mirandized, and in some instances denied medical assistance.
4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know.
Several police agencies raided a house, dragged individuals from bed, handcuffed and detained,
individuals without an arrest. Individuals were denied legal representations, were not
Mirandized, and in some instances denied medical assistance.
Page 1 of 4
5. The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Tustin Police Department
6. If amount claimed totals less than $10,000: Provide the amount claimed if it totals less than ten thousand
dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury,
damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of
the amount claimed (include copies of all bills, invoices, estimates, etc.)
Amount Claimed and basis for computation:
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
^ Limited Civil Case ^ Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
City of Tustin requests that you answer the following questions.
7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:
Carl Vincent "Vini" Bergeman, Anthony Michael Bergeman, Lorraine & Carmine Colarossi
LeRoy Guillory, Jennifer Bell, Altan Aksu, David Ryde, Erick Pimental, John & Kathleen D'Agostino
Scott Deere, Sr., Robert Green, Darren Johnson -All can be contacted through Richard Quintilone
8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
Approximately $100,000 in property damage to the residence as well as personal injury
damages, amount to be determined at trial.
if applicable, please attach any medical bills or reports or similar documents supporting your claim.
9. If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.: Telephone:
Address:
Insurance Policy No.:
Insurance Broker/Agent: Telephone:
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year:
Claimant's Drivers Lic. No.: Expiration:
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
Page 2 of 4
READ CAREFULLY
For all accident claims, place on following diagram name 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/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it,
and by "B" location of yourself or your vehicle when you first saw
SIDEWALK
City/Agency Vehicle; location of City/Agency vehicle at time of
accident by "A-1" and location of yourself or your vehicle at the
time of the accident by "B-1" and the point of impact by "X."
NOTE: If diagrams below do not fit the situation, attach hereto a
proper diagram signed by claimant.
CURB ~
PARKWAY
SIDEWALK
7
CURB ~,
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency may seek
to recover all costs of defense in the event an action is filed which is later determined not to have been brought in good
faith and with reasonable cause.
Signature:
Date:
Page 3 of 4
IF LATE CLAIM: COMPLETE ITEMS 1- 9 AND THIS APPLICATION.
SIGN BOTH FORMS.
APPLICATION FOR LEAVE TO PRESENT A
LATE CLAIM TO THE CITY OF TUSTIN
The undersigned hereby applies for leave to present a late claim to the City of Tustin. This application is being made
within a reasonable time, not exceeding one (1) year, after the accrual of the cause of action. Under some circumstances,
leave to present a late claim will be granted (Government Code § 911.6). The reason for delay in presenting the claim is:
Date
Revised 1212004
Signature of Claimant
Page 4 of 4