HomeMy WebLinkAboutC.C. 16 CLAIM 91-52 02-03-92CONSENT CALENDAR NO. lh
2-3-92
L'i E N
An
Inter -Com y
. y1
DATE: JANUARY 2 9 , 1991
TO: NONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIM WT: JOEL GORETH; D/L: 3.1-03-91; DATE PILED W/CITYI L2-
06-91; CLAIM NO: 91-52; CARL WARREN FILE NO2_8 66836 PRL
After investigation and review it is recommended that the
above -referenced claim be rejected and the city
claimant and to directed
to
the
give proper notice of the refection to the
claimant's attorney.
J ROURKE, City Attorney_
10114.h(m,0152 jtl)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
.Finance Director
City Manager
01-29-92 03:38?M HUM HUM & WUUUXUVP lu UZU043 ruU4/ UU i
City of Tustin
CLwIM XGAIDYST THE Cr T� OF x on 1 , PY party �
(For Damages to Persons o
The law P
rovides generally that a claim must be filed with aunt city Jerk of
the City of Tustin w after the incident or
your claim is agaiBe
nst the City of Tustin, not another public entity.
sure yo paper and identify
Whore space is insufficient, please use
i claims mus bs maxl.ed or
information by paragraph number. Conte
delivered to t Y
• he Cit Clerk, City of Tustin, 15222 Del Amo Avenue, Tustin,
California 92680
WEEN COIMPLETING THIS FORM' pLEASE TYPE OR USE BL&Q- -
TO THE H
ONOPABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following claim and information
relative to damage to parson and/or property:
1. a. NAME OF CLAIMANT
Joel Goreth
b. ADDRESS Off' CLAIMANT:
d. TELEPHONE NO:
e . DATE OF BIRTH:
f. SOCIAL SECURITY NO:.
g .
DRIVERS LI CENSE NO ! • —
2. Kamer telephone hone and post office address to which claimant desires notices
to be sent (if other than above) :
3. This claim is submitted against:
a. Y The City of Tustin only.
b. The following employees) of the City of Tustin only:
The Cit of Tustin and the following emplcYeg (s) of the City
C. Y
�~ of Tustin only:
4. Occurrence or event from which the claim aricas:
a. DATE:
b. TIME: '
C. PLACE (Exact and spe lip � s i tion)
Ma olia ark on slideoccur? Specify
d. HOW and under what circumstances did daA1act od'q omission you claim caused
the particular occurren�additiona paper if necessary):
the injury or damage (use
Child wad la ing do the slide. Lifted his head u and cut it on a piece of me{
atickiu u under the to art of the slide. Be re uiYe 4 st c es.
ul_LJ_dL UJ: Jorm rAULVl &UUAAE a r U"AUri, lv U.._QUL,� A uU�/ WU
WHAT partiCu__. action by the City,
or employees, caused the
alleged damage or injury?
Give a description o f the injury, property damage or loss so far known p
of head - taken Co
cut to top Pt
the g ,
e of this Claim. If there were no injur ie # state no injur es .
t1Y4 St. ' Jose h and had 4 st
chas
6. GiVe then
ames) of the City employee (s) causing the damage or injury:
7. Name and address of any other person injured:
a. game and address of the owner or any damaged property:
9. Damages claimed: 313.00
a. Amount claimed as of the date:
]3. Estimated amount Of future Costs:
c. -Total amount claimed.
s
d. Attach basis for computation of amounts claimed (include cop eof
all bills, invoices, estimates, etc•
io. Names and addresses of all witnesses, hospitals, doctors, etc.
_ Jessie Rozera
st. Joseph liosp.
WARNING: : IT IS A CRIMINAL. OFFENSE TO FILE A FAL%SB CLA1M s 556.0
(Penal Code Section 72: Insurance Code
matters and statements made in the above claimand at dow the
x have read the except as to those matte
same to be true of my own knowledge,
• or belief and as to such matters I bel�.eve, their aTRUEoAND
upon Information cnalty or perjuxy that �a foregoing
true. I oertify under p
CORRECT.
da of ,19 gam, at Tustin, California.
rxecuted this ., Y —
DATE FILED:
CLAII"iAN'r' S SIGNATURE .
gl:CLFORM
Revised 4/29/91