HomeMy WebLinkAboutC.C. 10 CLAIM 92-03 02-18-92CONSENT CALENDAR NO. 10
2-18-92
Lff" ' )"k A, -,- �
FEBRUARY 12, 1991
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CLAIMANT: SHARON RAGGHIANTI; D/L: 12-24-91; DATE FILED W/CITY:
01-13-92; CLAIM NO: 92-03; CARL WARREN FILE NO: S 66922 PRL
After investigation and review it is recommended that the
above -referenced claim be rejected and the City Clerk directed to
give proper notice of the rejection to the claimant and to the
claimant's attorney. — �
JAME,St�2Ot%CKZ, City Attorney
1 G R: jab: D:021192(CL-9203. jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin _
LM AGAINST THE CITY OF TUI- 'N
~ (For L ges to Persons or Persona :operty)
-he law provides generally that a claim must be filed with the City Clerk of
-he City of Tustin within 6 months after the incident
another public occurred.
entitye
sure your claim is against the City of Tustin, and identify
Where space is insufficient, please use additional paper y
information by paragraph number. Completed claims must be mailed or
delivered to the City Clerk, City of Tustin, 15222 Del Amo Avenue, Tustin,
California 92680
WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BLACK INR
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following
relative to damage to person and/or property:
9 -
NAME OF CLAIMANT:
ADDRESS OF CLAIMANT:
CITY/ZIP CODE:
TELEPHONE NO: 5�
DATE OF BIRTH:
SOCIAL SECURITY NO:
DRIVERS LICENSE NO:
I Q2
claim and information -
!
2. Name, telephone and post office address to which claimant desires notices
to be sent (if other than above):
3. This claim is submitted against:
a. X_ The City of Tustin only.
b. The following employee(s)
of the City of Tustin only:
c; The City of Tustin and the following employee(s) of the City
of Tustin only:
4.
Occurrence or event from which the claim arises:
a. DATE: bei. 24 /17
q�
b. TIME: !/= O -, H,
C. PLACE (Exact an speci is location) : Red /vd. nGL Oei/
north o k�QYne�' e — is/knd, in rn idd/G Feer'
veli S Specify
d. HOW an under what circumstances did damage or injury occur?
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper iE necessary):
�.1,dn ■..-7P A05-
[Or
WHAT particular action by the City, or its employees, caused the
5. Give a description of the injury, property damage or loss so far known at
the time of this claim. If t ere were no injuries, state "no in uries".
sc.�. — /c�'fNrf"
C -m G tom �6�/e / y h .% s b/
17Y1AM hi /o_ M dui W GG
6. Give
e name(s) of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured: Al one,
8. Name and address of the owner../ or any damaged pro erty:
-7-7V1 F0,17, i 1-406 C- // iW' / / ✓vT ' Yv / ✓ 1��/ V � Ovi/ Y /
9. Damages claimed:
O
a. Amount claimed as of the date: 557. ZO
b. Estimated amount of future costs: AL -
c . Total amount claimed: 557 Z to
d. Attach basis for computation of amounts claimed (include copies of
all bills, invoices, estimates, etc.
10. Names and addresses of all witnesses, hospitals, doctors, etc.
�e r�rd. L . Co•►�.rer�4a�r.C. /�$ �
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!!
(Penal Code Section 72; Insurance Code Section 556.0)
I have read the matters and statements made _in the above claim and I know the
same to be true of my own knowledge, except.
xcept as to those matters stated to be
upon information or belief and as to such matters I believe the same to be
true. I certify under penalty or perjury that the foregoing is TRUE AND
CORRECT.
Executed this 4 t,_ day of41;4u ,19 f.2—,, at Tustin, California.
DATE FILED: 9 .2L
CLAYMANT'S SIGMA
B1:CLFORM .
Revised 4/29/91
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