HomeMy WebLinkAbout10 CLAIM #94-10 04-04-94DATE: MAaCa 17, 1994
Inter-Com
TO: CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT= HILDA KRAMER; CLAIM NO: 94-10; D/L: 02-10-94; DATE
FILED W/CITY: 03-04-94; CARL WARREN FILE NO: S 78148 CLB
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.. ~OU~
City Attorney
JGR:jab:~ 17~(CL.-~ 10j~)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin
C_~M AGAINST THE CITY OF TU~ .~
(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 within 6 months after the incident-o~-eYe~t.'oc'curred. B~
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, 300 Centennial Way, Tustin,
California 92680
WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BLACK INK
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, Califdrnia:
The undersigned respectfully submits the following claim and information
relative to damage to person and/or property:
1. a. NAME OF CLAIMANT: Hilda V. Kr~mer
b. ADDRESS OF CLAIMANT:
d. TELEPHONE NO: (
e. DATE OF BIRTH:
f. SOCIAL SECURITY NO:
2. Name, telephone and post office address to which claimant desires notice~
to be sent (if other than above):
3. This claJ.m 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 or event from which the claim arises:
a. DATE: Feb.
b. TIME: 12: 30
c. PLACE (Exact and specific location): Tustln Senior ~enter !.~_r~e
Dinntn~ BoQm Rotary sDonsered Sweetheart luncnen
d. HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you ~laim cause-'
the injur
alkin~ behind the chairs of the
ooor. There was a 1o% of people ~ttln~ desert.
e leE of a chair was s%ickin~ out, a~u% ~ inches ana Hilca ca
e Pack of the chair.
Hllda fell, as a result ol ca%cnln~ 'net toe .... d ~h= fell ~ the floor
landln~ on her ri~h% side . She cracked th=ee ribs brt~sed her head & more..
e. ~qqAT particu, action by the city, o2 employees, caused the
alleged damage ~r injury?
Senior center, The le~s of the ~a~ir§-
behind the back of the chairs.
._
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".
Nilda's whole right side was bruised. She cracked three ribs and hurt her head.
Hilda had ~ cat-scare and X.~Rays of her ri~t side and back
6. Give the name(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: Will follow later.
b. Estimated amount of future costs: not sure will
c. Total amount claimed: note sure will file ikter
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. Witness Jerry mllsao ~
Dr. Earl Kiernan. 13420 newDort Suite H Tustin,Ca 926~0 -Dr. David holstein, 134~0
NewportAve. Tustin, Ca Tustin Hospii-al Newport Ave, Tustin , Western ?~eemcal
Hospital Tustin Ave.. Santa Ana. Ca.
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 3rd day of
March
,19 9~ , at Tustin, California.
DATE FILED: March 3rd 1 99~
~C~AIMANT' S S IGN~ATURE
B1 - CLFORM
Revised 4/29/91