HomeMy WebLinkAboutCC 4 CLAIM #92-43 11-02-92CONSENT CALENDAR NO. 4
11-2-92
AGENDA
Inter -Com
Inte
DATE: OCTOBER 15, 1992
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: MICHAEL MOTT; D/L: 8-8-92; DATE FILED W/CITY: 9-15-
92; CLAIM NO: 92-43; CARL WARREN FILE NO: S 72787 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. ,/� „ A&
JAM G. ROURKEI City Attorney
J0R:jab101592(CL.-9243 J&b)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of
mc. TM AGAINST THE
(For ,ages to Persons
11US:.1i1
CITY OF TU F" TN
or Personr roperty)
of
The law provides generally
that a claim must be filed With the Cccurredrk Be
Tustin within 6 months after the incident
another public ,entity.
the City of against the City of Tustin, n
sure your claim is ag paper and identify
space is insuff iCient, please use additional p P
Where p rah number. Completed claims must be mailed or
information by paragraph 15222 Del Amo Avenue, Tustin,
delivered to the City Clerk, City of Tustin,
California 92680
FORM, PLEASE TYPE OR USE _BLACK INR
WHEN COMPLETING THIS
MAYOR AND CITY COUNCIL, City of Tustin, California:
TO THE HONORABLE formation
The undersigned respectfully
oec y
relative to damageperson
l' a.
NAME OF
b.
AD DRESS OF CLAIMANT:
C.
CITY/ZIP CODE: '
d.
TELEPHONE NO:
e.
DATE OF BIRTH:
f.
SOCIAL SECURITY NO:
g.
DRIVERS LICENSE NO:
submits the following
and/or property:
nn .
•
claim and n
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. The City of Tustin only. of Tustin only:
b , The following of the City -- -- employee(s)
b
C. The City t of Tustin and the following employee (s) of the Citi
of Tustin only:
4. Occurrence or event from which the claim arises:
a. DATE:
a
b. TIME: p
C. PLACE (Exact and specific locatQ oS t : c , re- e �� \
ur
w
occur. Spec i f
d. HOW and under at ci cumstances di a da
ma
you claim causE
articular occurrence, the p event,Use additional p):_
or damage ( aper if necessaryI � d
the injuryi 5.,�-
e. wru;T pdr;.icu�CA:. A, I
alleged damacig injury?
P
5, Give a
descri tion of the injury, property damage or loss
tate so hoar kno n at
the time of this claim. If 001
were no � n�uciesA� YJA LZ
6, Give the name(s) of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured:
g. Name and address of the owner or any damaged property:
ZE
Damages claimed: the date: i4iE
a. Amount claimed as of
b . Estimated amount of future costs:
c. Total amount claimed:
J.' Attach
basis for computation of amounts claimed (include copies of
all bills, invoices, estimates, etc.
nna addresses of all witness hospitalst doctors, etc.
• T IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!! 0 .
WARNING. I )
(Penal Code Section 72; Insurance Code Section 556.
I have read the matters and statements made in the above claim and I known b(
tters
ed
same to be true of my own knowledge, except as to thos
emaeve the ta.t e to bi
upon information or belief and as tomatters
that the foregoing is TRUE AN;
true. I certify under penalty or perjury
er u ry
CORRECT.
�_
19 R �--, at Tustin, California
Executed this I day of e-
DATE FILED:
\ C1 TIS SIGNATURE
s Ro-,o C,
B1:CLFORM
Revised 4/29/91
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