HomeMy WebLinkAbout04 CLAIM #94-17 06-06-94AGENDA____.
Inter-Corn
NO. 4
6-6-94
DATE:
MAY 9, 1994
TO: HONOP~tBLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CL~I~: FRED KASR~; CLAIM NO= 94-17; D/L: 04-04-94; DATE
FILED W/CITY= 04-13-94; CARL W]~REN FILE NO= S ?8239 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.
City Attorney
~GR0~:QS06~CL-~ 17.~b)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
city Manager
City of Tustin ~
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Persons or Personal Property)
The law provides generally that a claim must be filed with the City Clerk of
the City of Tustin w~th~D 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 mail.ed or
delivered to the City Clerk, City of Tustin, 300 Centennial Way, Tustin,
California 92680
WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BI~CK INK
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:
b. ADDRESS OF CLAIMANT:
c.. CITY/ZIP CODE: /
e. DATE OF BIRTH: ~.
f. SOCIAL SECURITY NO:
g. DRIVERS LICENSE NO: _
i
2. Name, teiephone and post office address to which claimant desires notice~
to be sent (if other than above):
3. This claim is submitted against:
a. _.// The City of Tustin only.
b. The following employee(s) of the City of Tustin only:
Ce
The City of Tustin and the following employee(s) of the City
of Tustin only:
4. Occurrence o~ event,from which the claim arises:
a. DATE:j_ _
C. PLACE (Exact and specific location): ~,~ ~,==
d. HOW and under what circumstances did damage or injury occur? Specif
the particular occurrence, event, act or omission you claim cause
t~e injury or damage (Use additional paper if necessary):
H
e.
WHAT particU..' action by the City, or xts employees, caused the
alleged damage or injury?
5. Give a description of the injury, property damage or loss so far known at
theft)me of this claim. If there were no injuries, state "no injuries".
·/,3g~£,~,
6. Give the,~ame(s) of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured:
8. Name and address of the .owner or any damaged property:
9. Damages claimed:
a. Amount claimed as of the date: · I~q. ~
b. Estimated amount of future costs: ---
c-. Total amount claimed: ~ I~. i~ .~ ..
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.
;
'.
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 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 ! t day of
CLAIMANT ' S SIGNATURE
,19 ~/, at Tustin, California.
BI: CLFORM
Revised 4/29/91
GLZkSS-]
FRED KASRA
** QUOTE
CUSTOMER / SALE
:-PURCHASE ORDER NO=:t PAGE N
CUSTOMER NO.=I ! CUSTOMER' NO
I
04/0.7/94
;EOF- LOSS
DEDUCTIBLE
HONDA
ACCORD
· 00
ODOMETER-
**NOT AN.INVOiCE DO NOT PAY:
--FERRED BY
GOOD FOR 3~ DAYS**
FOR OFFICE
USE ONLY
REPAIR COMPLETED?
kss INSPECTION
E & DESCRIPTION OF DAMAGE
rE: THERE IS A CHANCE THAT THE WINDSHIELD MAY FURTHER BREAK
DURING THE REPAIR PROCESS. U.S. AUTO GLA~S WILL NOT BE RESPON-
SIBLE IF THE WINDSHIELD SHOULD BREAK FURTHER WHILE Al'tEMPTING
THE REPAIR. YOU WILL NOT BE CHARGED FOR THE REPAIR.
SERVICE TECH. SIGNATURE
CUSTOMER SIGNATURE
3TRUCTIONS:
' 594,90 165.9 .00
'~7 ..... . ~ ~ ., ~l . ·
CA 10. ~.S SALES 13.
ORAN'SE 2, 56 TAX
~~. GROSS
PAYMENT
RECEIVED
.0
01
I. B4. 1"
STATEMENT OF FINAL AND SATISFACTORY COMPLETION AND AUTHORIZATION TO PA'
THE UNDERSIGNED ACKNOWLEDGES RECEIPT OF THE ABOVE REFERENCED GOODS AND SERVICES AND ACKNOWLEDGL
HE/SHE HAS INSPECTED SAME AND IS SATISFIED THERE WITH. THE UNDERSIGNED FURTHER ACKNOWLEDGES A
SERVICES WERE PERFORMED IN A WORKMANLIKE MANNER TO HIS/tIER SATISFACTION AND AUTHORIZES THE INSURANf
COMPANY TO PAY U.S. AUTO GLASS DIRECTLY FOR PAYMENT OF THIS CLAIM. THE UNDERSIGNED AGREES THAT HE/~HE
PERSONALLY RESPONSIBLE FOR PAYMENT OF THIS INVOICE IRRESPECTIVE OF ANY INSURANCE COVERAGE WHICH M,
PERTAIN HERETO.
**NOT AN INVOICE DO NOT PAY, GOOD FOR 30 D~YS**
Q SIGNATURE DATE
U.S. Auto Glass Centers
3~3 SOUTH HARBOR ~A
SANTA ANA CA 92701
(714) 531-855[~
;-SERVIC,. ri.
MOBILE SERVICE LOCATION