HomeMy WebLinkAboutCC 9 CLAIM #92-55 02-16-93CONSENT CALENDAR NO. 9
r 2-1fi-93
AGENDA
ATE: JANUARY 27,r 1993 Inter -Com !ww
S
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: JESUS RAMIREZ; CLAIM NO: 92-55; D/L: 11-3-92; DATE
FILED W/CITY: 11-13-92; CARL WARREN FILE NO: S 73834 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.
JAMES 6,Z ROUITf City Attorney
JGR:jab:(CI-9255 jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin
LM AGAINST THE CITY OF T .N
(For Damages to Persons or Personate Property)
—The law provides generally that a claim must be filed with the City Clerk of
:he City of Tustin within 6 months after the incident or event occurred. Be
sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify
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 claim and information
relative to damage to person and/or property:
1. a. NAME OF CLAIMA
b. ADDRESS OF CLA
C. CITY/ZIP CODE:
d. TELEPHONE NO:
e. DATE OF BIRTH:
f. SOCIAL SECURIT
g. DRIVERS LICENS
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. V 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: r ! 3 % q1
b. TIME: -
4 3c, ,rn.
C. PLACE (Exact and specific location) : Ic-t-
1 OI 1fC' . u_5tsyjl CA s a b, 7 (71 0959--1300
d. HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the inlury or damage (Use additional paper if necess.�ry): -
fl_
e. WHAT particul action by the City, or `s employees, caused the
alleged damag r injury?
5. Give a description of the injury, property' damage or loss so far known at
the time of this claim. If there were no injuries, state "no injuries".
Frov+ tk,,incl Sn21^_i i S Shc•- "erc fe�-F -erde 1.5 den-i-e6^h onci s Gl,so
e.
,d (Linn bie tc •u!heei
GCe.,r- Q%r% notSe
6. Give the name(s) of the City employee(s) causing the damage or injury:.
7. Name and address of any other person injured:
S. Name and address of the owner or any damaged property: (Te 5 u S A ✓.A• )D S
11015 n CA, g005ci --
9. Damages claimed:
a. Amount claimed as of the date: LkYi Know; ►'1
b. Estimated amount of future costs: u n Kn e w ►i
C. Total amount claimed: L► n Knntjoyl
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.
M ri L.
L,ort ' rke_e-� --
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 }snow the
same to be true of my own knowledge, except as to those matters stated to be
uvon information or belief and as to such maters I believe the same to be
true. I certify under penalty or perjury that the foregoing is TRUE AND
CORRECT.
Executed this day of N C �^n'J �--;' , 19 ► o , at Tustin, California .
DATE FILED:
CIJ 1ANT'S SIGNATURE
B1:CLFORM
Revised 4/29/91