HomeMy WebLinkAboutCC 4 CLAIM #91-36 11-04-91CONSENT CALENDAR NO. 4
//_; 11-4-91
M
AGENDA -
DATE: OCTOBER 15 1991 Inter -Com
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: RICHARD A. VASILTA; D/L: 07-16-91; DATE FILED
W/CITY: 08-06-91; CLAIM NO: 91-36
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 tr4,ly 'our -S,
JAMES G ROURKE
City Attorney
JGR: jab(CL-9136. jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin _
C K AGAINST THE CITY OF TUS'
(For Dar. ,as to Persons or Personal )perty)
`-e 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
,,are 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 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 nand/or property:
1.
a. NAME OF CLAIMANT: �k'
b. ADDRESS OF CLAIMANT:
C. CITY/ZIP CODE: �
f. SOCIAL SECURITY 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: -?— 1 C. — 9 1
.
b. TIME: 11 3 o Q.,
C. PLACE ( Exact and i(f/tr}ic
location) : oz0
(spec
d. HOW and under what circumstances did damage or
injury occur?
Specify,
the particular -occurrence,
event, act or omission
you claim caused
the inju y or damage (Use
additionalpaper i
necessary):
/
10
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Au_
..wn,.��...1 i 10. A- i1 0 rA.I I I I I G
MI�t� �I��'L Oo A-.—, k kP'f—
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e. WHAT particular -action by the City. or its employees, caused the
alleged damage injury?
5. Give a description of the injury, property damage or loss so fdr known at
the time of this claim. If there were no injuries, state "no injuries".
0KQ ,l. �Ge,.,
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.
c. Total amount claimed:
d. Attach basis for computation of
all bills, invoices, estimates,
l ) . o 0-4)
t o , opo _ t -J
Z3. oa a . ev
amounts claimed (include copies of
etc. 4NJus- cher Yler- J-;� �►c�. F; - ��c,t s.
10. Nimes and ad4resses of all witnesses, hospitals, doctors, etc.
►)�_ � n� ► � i) ��a gbh( t,�c I��� , �� C�u--i�-�--iirt.• � � c.►t�-�. �+Q*ty� ,
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 mode 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 -� day of
DATE FILED:
E
rsl : CLFORM
Revised 4/29/91
Not.. 1S's
, 19 _, at Tustin, California.