HomeMy WebLinkAboutCC 3 CLAIM #90-21 08-20-90DATE:
TO:
FROM:
SUBJECT:
July 31, 1990
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CONSENT CALENDAR NO, 3
8-20-90
Inter - Com
CLAIMANT: Adeline Carrasco; D/L: 6/15/90; DATE FILED
W/CITY: 6/19/90; CLAIM NO: 90-21; CARL WARREN FILE NO:
RAIAR5PRT.
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.
r
JAMES G. ROURKE
City Attorney
JGR:kbg(claim.frm)
Enclosure: Copy of Claim
i'
CLAIM AGAINST THE CITY OF TUSTIN
-- (For Damages to Persons or Personal Property)
Received by via
U.S. Mail
Inter -office Mail
Over the Counter
TTT-e iaw provides gener-ally tTiat a claim must be file -d file-dwith the Cityclerk of
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-
tion by paragraph number. Completed claims must be mailed or delivered to the
City Clerk, The City of Tustin, 300 Centennial Way, Tustin, California 92680
-TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following claim and information Tela
tive to damage to persons and/or per-,onal property:
r
1. NAME OF CLAIMANT:
a. ADDRESS OF CLAIMANT-: "-
b. PHONE NO : (� ) DATE OF BIRTH: /
SOCIAL DRIVERS
d. SECURITY NO: %�- �� ' e. LICENSE NO:
2. Name, telephone and post office addre s 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 employees) 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: �; �� o b. TIME:
? C. PLACE (Exact
and specif is 1 cation) : - i
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 dam ge (Use. additional paper if necessary).
e. What parteFar action b the City, or its employees, caused the
alleged damage or, in,
Give 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
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 ad ress 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: C
d. Basis for computation of amounts claimed (include copies of aIl bills,
invoices, estimates, etc.:
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
a.
ce
d.
_Ll. Ani additional information that might, be elpful n Considering this claim:
14,1 A- ) _�J /M 1 . - .
C4�e� Iry • ��
WARNING: IT IS A CRIIIINAL OFFENSE T.0 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 /fZ' "day of ,�,�. ; 19 O at Tustin, California.
--Office of the City Clerk,
^ustin, California
CLAIM NO:
Revised 8/05/81
JGR: se : R: 8/5/81 (A)
MR.-Illiva 1412,015M
DATE FILED: / O
S 0 T 0 ASTI JW.�2
(7 14.) 220-09:2
SOLD UV
VAIU OUT
12
CUSTOMER'S ORDER NO,
17CC. U UY
KEEP THIS SLIP FOR REFERENCE
51-528/01528 RF�trORM