HomeMy WebLinkAboutCC 3 CLAIM #91-37 09-03-91AGENDA- ��
ATE: AUGUST 21, 1991
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
CONSENT CALENDAR NO. 3
9-3-91
SUBJECT: CLAIMANT: JENNIFER JOUBRAN; D/L: 07-22-91; DATE FILED W/CITY:
08-02-91; CLAIM NO: 91-37; CARL WARREN FILE NO: S 66564 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.
Verytr y rs,
JAME OURKE
City Attorney
JGR: jab:082191(CL-9137. jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin
C H AGAINST THE CITY OF TUI
(For Damages to Persons or Personal ..roperty)
_e law provides generally that a claim must be filed with the City Clerk of
a City of Tustin within 6 months after the incident or event occurred. Be
sure your claim is against the City of Tustin not z ' ' reciC�� Y-
Where space is insufficient, please use additional Ey
information by paragraph number. Completed claim' )r
delivered to the City Clerk, City of Tustin, 15222 D duV �!'�J
California 92680 a4
WHEN COMPLETING THIS FORM, PLEASE TYPE OR Uty�O _ /,,i„ 00-
L)
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, i-alirornia:
The undersigned respectfully submits the following claim and information
relative to damage to person and/or property:
1. a. NAME OF CLAIMA
b. ADDRESS OF CLA
C. CITY/ZIP CODE:
d. TELEPHONE NO:
e. DATE OF BIRTH:
f. SOCIAL SECURIT
g. DRIVERS LICENS
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 ,h* h the claim arises:
a.
DATE: (.i
b. TIME: •so PM
C. PLACE (Exact and specific location) : Qli 1 Pku" 9CF-0P.r
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):
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e. WHAT particula- Iction by the C� or employees, caused the
alleged damage injury?
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5. Give a description of the injury, property damage or loss so far known at
the time of_this claim. Ino ozf there were no injuries, state "no inju ies".
lef eX, L I
6. Give the name(s) of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured:
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8. Name and address Qf the �ow Tr
or �ny damaged property:
U'i n i e +' ��� U 12 r0.r1 , uJ t t1 0 t,� h I Ci
9. Damages claimed:
a. Amount claimed as of the date: �s�,�[n. •_�U
b. Estimated amount of future costs: .�
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 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 Y AJI� da of, 19 1 at Tustin, California.
DATE FILED:
CL�AZMA%T' S S GNATUR
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Revised 4/29/91
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