HomeMy WebLinkAboutCC 3 CLAIM #91-2 03-04-91I -14i E�F
DATE:
TO:
FROM:
February 19, 1991
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CONSENT; g4WADAR NO. 3
3-4p 91
Inter - Com
SUBJECT: CLAIMANT: STEVE RUHLAND; D/L: 12/11/90; DATE FILED
W/CITY: 01/15/91; CLAIM NO: 91-2; CARL WARREN FILE NO: s 64122
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.
E G T. ROURAXE
City Attorney
JGR:kbg(claim.frm)
Enclosure: Copy of Claim
t City of Tustin ,
Ci I AGAINST THE CITY OF TUSH.
(For Damayes to Persons or Personal Property)
�'he law provides
generally that a claim must be filed with the
City
Clerk of
.ie 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
to be sent (if othe than above):
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:
t'
1. a. NAME OF CLAIMANT: ,
b. ADDRESS OF CLAIMANT,.- ,
C. CITY/ZIP CODE: �'
) n Ul"_
d. TELEPHONE NO:
e 'DATE OF BIRTH:
f . SOCIAL SECURITY NO:
g . DRIVERS LICENSE NO: '�--
�-Ai) f =
2. Name, telephone and post office address to which
claimant desires notices
to be sent (if othe than above):
3. This cla is submitted against:
a. The City of Tustin oni;- .
b. The following employeebs) 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 ; L1
b. TIME:
C . PLACE�Exact nd specific location) 0 row
�1
d. HOW and under what circumstances did damage or injury occur? Specify
- the particular occurrence., event, act or omission you claim caused
the i� ury_or damage (Us additional pger if necessary) : ;� y.
e. WHAT particular; .tion by the City, or ii, !mployees, cased the
wed damage L, in ' u ? j;
C a U N 41-
o
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
A
j urie It .
R 1--7,
lei �/ f ice.o •'�<• - �--
6. Give the names of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured:
8. Name and ,add: ess ofz Lice � une-*3r a.,y damage:; property:
9. Damages claimed:
a. Amount claimed as of the date:
b. Estimated amount of future c(:)sts : M p 6 ; z; -c/'
C. Total -amount claimed:
d. Attach basis for computation -of amounts claimed (include copies of
all bills, invoices, estimates, etc.
i
10. Names and a resses of all witnesses, hospitals, doctors, etc. ,
= CCS �i� ef"C—
�—
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!!
(Penal Code Section 72; Inwirance 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
•� a+-�r. �r pol i cif ar�.`i a + cz^� }� Matters "^ rc T believe ...r.. _ '=^ C _i cave the* came to 1- e
true. I certify under penalty or perjury that the foregoing is TRUE AND
CORRECT.
Executed thi day of at Tustin, California.
DATE FILED • / 7169-
CLAIMANT'S SIGNATURE
x,�/.�
Bl:CLFORM
Revised 10/23/90
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