HomeMy WebLinkAboutCC 3 CLAIM #89-4 05-15-89 , ., ~'~ CONSENT CALENDAR
,_ /_~ .~'" ~4'¥ ~ 5-~s-89
AP~ I ~ 1~9
T0: HONO~LE ~YOR ~ CI~ COUNCIL
FROM: CI~ ~~Y
SUBJECT: CLAIMANT: CONSUELO BURGOS; D/L: 2/28/89; DATE FILED
W/CITY: 3/6/89; CLAIM NO: 89-4; CARL WARREN NO. S57702PRB
After investigation and review it is recommendea that the above-
rererenced c-aim be rejected aha the City Clerk airected to give
proper notice of the rejection to the claimant and to the
claimant's attorney.
,
,
City Attorney
JGR(F4.se)
Enclosure: Copy of Claim
CLAIM AGAINST THE CIT:~ TUSTIN
t('For Damages to Persons or Personal Property)
· S. Mailu
~nter-office Mail
via
Over the Counter ' . ~ O~ic~|nCi~C~rk
-
...S~ ~?...% ~ ~,.,~_ .
The law prey'ides generally that a claim must be filed wit4j the :Y C~erk O~
the City of Tustin. within 100 days after which 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 informa-
.%.tied by'paragraph number. Completed claims must be mailed or delivered to the
.... 'City Clerk, The City of Tustin, 300 Centennial way, Tustin,.Califbrnia 92680
"TO. THE'HONO~LE MAYOR AND CITY COUNCIL, City of Tustin~ California:
:; ·
The undersigned respectfully submits the following claim and information rela-
.itive to damage to persons and/or personal property:
b.SOCIALPHONE' NO: (" /--'-.., /~, ..... ,?/ ~c DATEDRiVERsOF--B-iRTH: . ~/..,
d. SECURITY NO: (~ ,/ e. LICENSE
2. Name, telephone and post o'ffice address to which claimant desires notices
to be sent, if other than above:
I
· This claim is' submitted against:
a .~.'
· _ The City of'~ustin only.
b. The following employee(s) of the City of Tustin only:
C ·
i
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: ~-'~--~ u7 b. ~~ ,~' O~ .~' l'~'~c. PLACE (Exact'
and specific location): , e_[710 ~. ~%a'~F~.dda~
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 n~cessary). .
e. What particular action by the City, or its employees~, caused the
alleged damage or. inj
· d ; {nq ch*ur /
!
'5... ~ive a description of the injury, property damage or loss so far as is
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) eau-sing the damage or injury:
b, 'ncnD, n e. tc
7.. Name and address of any other person injured:
· .
.8. Name and address of the owner of' any damaged property:
9'. Damages' claimed:
,. a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed:
, , i.
d. Basis for computation of amounts claimed ('include copies of all bills,
invo'ices, estimates, etc.:
10. Names and addresses of all witnesses, hospita!s,_doctors, etc.:
i i i
.
.
~ ~y additional info,erich ~hat might be helpful ~n considering ~his' claim:
· i I
WkRNING: IT IS A CRIMINAL OFFENSE T.O 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 of perjury that the foregoing is TRUE AND CORRECT.
Executed this ,.% day of ~~C.~i , 19 ~ , at Tustin, California.
Office of the City Clerk,
Tm~tin, California
~._.,IM NO: ~_
·
Revised 8/05/81
JGR:~e:R:8/5/81 (A)
CLAfMANT ' S SIGNATURE
DAT'E FILED: