HomeMy WebLinkAboutCC 4 CLAIM #91-17 06-03-91AGENDAC. -3 -111
ATE: MAY 141 1991
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
,CONSENT CALENDAR NO. 4
r
6-3-91
v
Inter-C1om
SUBJECT: CLAIMANT: CESARIO MONTOYA; D/L: APRIL 26, 1991; DATE FILED
W/CITY: APRIL 11, 1991; CLAIM NO: 91-17; CARL WARREN FILE NO:
S 64339 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.
Very 'tru 1y,,yours
JAMES G. ROURKE
City Attorney
JG R: jab:5-14-91(CL-9117. jab)
Enclosure: Copy of Claim
City of Tustin
C AGAINST THE CITY OF TM. _.
(For Damages to Persons or Personal Property)
_,e law provides generally that a claim must be filed with the City Clerk of
e 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, 300 Centennial Way, 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:
NAME OF CLAIMANT: `Psi67,,r
ADDRESS OF CLAIMAN :
-
CITY/ZIP CODE:
TELEPHONE NO: '
)
--
SOCIAL SECURITY NO:
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• q e
C. PLACE (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 injur or damage (Use addition4l paper if necessary):
e. WHAT particular ,tion by the City, or i _:mployees, caused the
alleged damage or injury?
r -
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".'
6. Give the name (s) of the City employee(s) causing the damage - or .injury :
vim � � v�✓ f��- c� n ;, C I _, � �
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: f .1 G -e cA<- J
b. Estimated amount of future costs; cam; t
C . Total amount claimed:
d. Attach basis for computation of a ounts claimed (include copies of
all bills, invoices, estimates, etc.
10. Na es and addresses of all witnesses, hospitals, doctors, etc.
-- /l .i - - 7 1 \/ <--
WARNING:
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 1'r% day of ,19 % , at Tustin, California.
DATE FILED: Z/ —/1
CLAIMANT'S SIGNATU
Bl:CLFORM
Revised 10/23/90