HomeMy WebLinkAboutCC 4 CLAIM #88-1 08-01-88 i i
DAT£: July 18, 1988
·
T"0: ItONOR/~r.E I~¥OR ~ CI~ COUNCIL'
~RO~:
CI~fY ATTORNEY
$ UBJ [CT:
CLAIMANT: WEISS, 'ADAM NF__AL ; D/L: 11/10/87 DATE FILED
W/CIT~: 1/7/88 ; CLAIM NO: 88-1 ; CARL WARREN FILE NO:
S52977CLH
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.
· ~A~ES-. ~. ROURKE
City Attorney
;'GR (F4. se)
Enciosur e:
Copy of Claim
CLAIM_ AGAINST THF ' Y OF m.~STIN
.('For ~Damages to ,~ns or Personal Propertl
ReceivEd by
U.S. Mail
Inter-office Mail
Over the Counter
via
The'"law provides generally that a claim must be filed with the City Clerk of
the City of Tustin within 100.days after which the incident or event occurre~
Be sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify inform~
tion by paragraph number. Completed claims must be mailed or delivered to ti
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 rel~
tire to damage to persons and/or personal property:
a. ADDRESS OF CLAIMANT: :~
b. PHONE NO: (% ~ c.~ DA~E OF BIRTH:
SOCIAL DRIVERS
d. SECURITY NO: . , ..... e. LICENSE NO: /, ~>~.
2. Name, telephone and post office address to which claimant desires notice~
to be sent, if.other than above:
.3. This claim is submitted against:
a. X The City of Tustin only.
b. The following emplOyee(s) of the City of Tustin only:
The City of Tus:in and the following employee(s) of the
City of Tustin only:
C ·
Occurrence or event from which the claim - ~
=r.ses:
a. DATE: ~!1%6!~T~~ b. 'TIME: ~ '-~0 ~' c. PLACE (Exact
and speci'fic' location): O~u.~{~,~. ,u~'.~..~ ~'~_~ ~.,~,~%~. ~. --,-.~=~. ~
,
d. How and under what circumstances did damage or injury occur? Specif'
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use 9dditional paper if necessary)..
e. What particular action by the City, or its employees, caused the
alleged damage or injury?
4 '
Give a descript~va of the injury, property _~mmge or loss so fa~ as is
known at the time of this claim. If there were no i~j~ries, ~s~e "~o
injuries".
6. Give the name(s) of the City employee(s) causing the da. mage or injury:
7. Name and address of any other person injured:
8. Name and address of the owner of any damaged property
Damages claimed: ~¢on-,+~~-
9. a. Amount claimed~s of this date: ~?-) Op O
b. Estimated amount of future costs:
c. Total amount claimed:
d. Basis for' computation of amounts claimed (zncAu~e{ copies of ali Silis~
invoices, estimates, etc. :
10~ Names and addresses of all witnesses, hospitals, doctors, etc.:
,,
!1,. ~y additional info~ation that' might be helpful in considering this claim
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
. . m~e~s'stated to be
same to be true of my own knowledce~ except as to those -~' -
upon information or belief and as to'such matters I believe the same to be tru
i certify under penalty of perju~ that the foregoing is TRUE AND CORRECT,.
Executed this c.._.
_.
'Office' of the City ' Clerk,
Tustin ,"' California
CLAIM NO: ~, .,~-- ,/
Revised 8/05/81
JGR:se:R:8/5/8! (A)
day of ~,,'c~'~,4 - , 19 --~-, at Tus~:.n, _.-
--/---~ CLAI~ANT ' S SIGNATURE
DATE F.,.ILED: _~.,,