HomeMy WebLinkAbout05 CLAIM #93-16 02-22-94NO. ~
2-22-94
DATE:
FEBRUARY 4, 1994
I'nter-Com
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: JEAN VALLANDIGHAM; CLAIM NO: 93-16; D/L: 05-07-93;
DATE FILED W/CITY: 05-14-93; CARL WARREN FILE NO: S 74199 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.
JAMEsOn. ~ROURK E
City Attorney
3OR:jnb:020494(CL-9316.jab)
Enclosure: Copy of
Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin
Cl ,GAINST T~R CITY OF TUS~
(For Damages-to Persons or Personal rroperty)
--
The law provides generally that a claim must be fkled with the City Clerk of
the 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 INK
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tus'tin, 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:
d. TELEPHONE NO: ( ?/~
e. DATE OF BIRTH:
f. SOCIAL SECURITY NO:'
g. DRIVERS LICENSE NO:
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.
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: ~- ~- ~/
b. TIME: ~:-¢~ ~ X], ~.
c. PLA_CE (Exact and specific location): ~$~¢.~
d. HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use, additional paper if necessary):
fl. , ~. '', ·
l_ t ) A r .~ ~- , -1- ,3 , c~ , ... ' lf z~ -- C ,? ~ ~ # ~- X;~ , ~, :~b o-/- ~ -~A l l h, ~ : n ~
e. WHAT partic - action by the City,
alleged dama~ or injury?
'~s employees, caused the
5. Give a description of the injury, property damage or loss so f~r known at
.the time of this claim. If there were no injuries, state "no injuries".
/
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: ~-
b. Estimated amount of future costs: ~.t~8!&
c. Total amount claimed:
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 FIT.~ 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 /0~ ~ day of
,19__~, at Tustin, California.
DATE FILED:
Specialty Care for the Entire Family
Bi'CLFORM
Revised 4/29/91
JOHN A. SARKARIA, M.D.
Adult Internal Medicine and Pediatrics
14642 Newport Avenue. Suite 210
Tustin, California 92680
Telephone: (714) 669-4449