HomeMy WebLinkAboutCC 5 CLAIM #91-19 06-03-91A r-2 P Ri n A Q
CONSENT CALENDAR NO. 5
'6-3-9,1
MAY 14, 1991 Inter-com \ ��
ATE:
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: GARY M. SNYDER; D/L: APRIL 9, 1991; DATE FILED
W/CITY: APRIL 16, 1991; CLAIM NO: 91-19; CARL WARREN FILE NO:
S 64353 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.
/; 7
Very may. ;.your
J",FdS (:—,: ROURKE
City Attorney
JGR: jab:5-14-91(CL-9119. jab)
Enclosure: Copy of Claim
• City of Tustin
C AGAINST THE CITY OF TUS
(For Damages to Persons or Personal Property)
law provides generally that a claim must be filed with the City Clerk of
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:
1. a . NAME OF CLAIMANT : & ry tA 5n y O(e r
b. ADDRESS OF CLAIMANT:
C. CITY/ZIP CODE:
d. TELEPHONE NO: / '
f. SOCIAL SECURITY NO: -
2. Name, telephone and post office address to which claimant desires notices
to be sent (if other than above):
S(7ph e
3. This claim is submitted against:
a._ The City of Tustin only.
b. The following employee(s) of the City of Tustin only:
4.
C. The City of Tustin and the following employee(s) of the City
of Tustin only:
Occurrence or event from which the claim arises:
a. DATE: IFr1. (:'/ 19C'f
b. TIME: :t �2 ' 3 O M
C. PLACE /�(Exact d specific location) : & w Pw
dhrl ,`c� rT'i ay h ( is n k ve .
d. HOW and under what circumstances did damage or injury occur?
the particular occurrence, event, act or omission you claim
the in•u or damage (Use additional Taper if necessary):
Sh a(4 60u4 -d hole C 0 N"e rave 0VIC r t r yCA
d C/ tv L -G It W 4-C V-va k 1 1 h k e r' ' o �k C I Q n(Q d ✓0.t U r► P" h
Specify
caused
w
o r
a i. c n roc... ter,( n /1 over- Ai\/ C a v, .n , e1 w� h ds , p C y.- 1'5 a N I r-rg h -3 o '�
e.• WHAT particular
alleed damage
lrrfe_tiC(ft 944
.tion by the City, or
inj ur?
d oorYy _r z4 rJCac e d Ar -
it
employees, caused the
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". ,
0 'V% T'AM'PS , Cdr w�l� r''e ufrf ei WO.S re � uP It, Col
Qr7r4C iked. C,),--
N;,cson 300 ZX
6. Givethe names) of the City employee(s). causing the damage or injury:
N
7. Name and address of any other person injured:
rq/,1- -
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:
C. Total amount claimed: /a.S
d. Attach basis for computation of amounts claimed (include copies of
all bills, invoices, estimates, etc.
1Q. Nam s and addresses of all witnesses, hospitals, doctors, etc.
NIA
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 day of A0 ( ,19 at Tustin, California .
DATE FILED: / 9l
CLAfMAW 'S SIqATURE
B1: CLFORM
Revised 10/23/90
A.
ILING
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0•
A NO• A 9'669
------ (714) '1744-2592
NAME DATE
ADDRESS
SOLD By CASH HARCr�on: Accv. mosc. PA#oc)ur
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KEEP THIS SLIP FOR REFERENCE
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