HomeMy WebLinkAboutCC 3 CLAIM #87-31 12-21-87CONSENT CALENDAR
NO. 3
TO:
FROM:
HONORABLE N~YOR ~ CITY COUNCIL,-.-/'
-
CITY ATTORNEY
S UBJ E:CT:
CLAIMANT: PATRICIA DANE; D/L: 6/24/87; DATE FILED
W/CITY: 8/28/87; CLAIM~NO: 87-31; CARL WARREN FILE
NO: S5271PRC
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
i ~'3': &
~~' G. ROURKE
claimant's attorney.
City Attorney
JGR (F 4. se )
Enclosure:
Copy of Claim
dLAIM AGAINST THE CITY '" TUSTIN
('For Damages to Persor. or Personal Property)
Received by ~t~ ~, ~,D via
U. S. Mail ¢ ~--
Inter-office Mail PO ~_{C_~- ~-~~
Over the Counter ~--
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 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 rela-
tive to damage to persons an.~/~r personal proper~,:
a. ADDRESS OF CLAIMANT /~~ / ':/~'~-~/'"'~/~"~"
b. PHONE NO: (~/~) ~ -~ / c. DATE OF BIRTH:
SOCIAL . __..,~ /~ ;~/- ~ DRIVERS
2".. Name, telephone and post office address to which claimant desires.notices
to be sent, if other than above:
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 b. 'TIME: ~ '. ~O ~-~ ..... c. PLACE (Exact
and specific location): ~'%qql ;.4~?-~1.+~-~ -~_~_,-~,~3-I~ST~F~
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 necessary).
e. What particular action by the City, or its employees, caused the
alleged damage or injury?
5. Give a description ot the injury, property damage or loss so far as is
known at the time of this claim. If there were no injuries, state "no
~.njuries".
--
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 of any damaged property
9. Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed: .
d. Basis for computation of amounts claimed (include copies of all Dills,
invoices, estimates, etc.:
·
10. Names and addresses of all witnesses, hospitals,, doctors, etc.:
a.
b.
Ce
11. Any additional information 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
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
Office of the City Clerk,
·
Tustin, California
CLAIM NO: ~ 7-~/
19 ~7 , at Tustin, California.
CLAIMANT ' S- BIGNAT URE
Revised 8/05/81
JGR:se :R:8/5/81 (A)
SANTA Ai, A LINCOLN MERCURY
1301. NORTH TUSTIN AVE · SANTA ANA, CA. 92701 · (714) 547-0511 ALL REPAIRS GUARANTEED'_7,/../.,,
- ', POLICY NO.
A~RE~ ADJUSTER .TEL. ~
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OPEN ITEMS PL,AS, R~D CARE~LL, BEFORE SIGNING SUB TOTAL S ~: /
~TICE. P~t~nl a~ d~ ~a~g~ m~ ~ ~ I~ s~al s~e ~ lle~ ~ avai~ B.A.R NO. AJ-10~55
~tly. OA~GEO ~ BROKEN Oa~s r~ f~ ~ ~ ~ junk~ ~s ~ ~ll~ll US O1~ '
in wnt~. If NEW PARTS lisl~ ~ ~ r~r~ am ~T ava~le. ~ r~ I~ r~hl Io P~e POWER OF A~ORNEY PARTS $ , /.
~SED PARTS a~ REPAIR s~ ~ m ~ oa~s. ~e ~e. Ihe CHARGE [~ ~ ~e ~m~. ~ereinafl~ ~11~ "Insure" f~ the ~ns~eral~ -.
' ~ m~ ~ an ~ual li~ b~s al ~r ~ la~ rale ~ ~. ~e ~ is an
SUBLET /~2~ '~
~ ~ I~ inl~m ~e. ADDITIONAL ~. ~ la~. may a r~N m~,y a~ Ihe ~ of r~ m~ Io "Inlur~'l" aul~i~, made Io Insur~'s enlire NET
slan~ ~ ~ u~. ~1 m~ ~ ~ ~,~ are I~ m~ W~ ee ~ ~1 yl~l~m ~ FREEWAY AUTO BODY ~ hefty granl Io FREE- · "' '-' '
~n I~ lir~l ~n~, S~ AOOITIONAL ~R AND aATERIAL WILL BE CHARGED FOR IN WAY AUTO ~OY Insur~'s ~ of all~ne~ Io sign or e~ SALES
AOOITION TO ~E A~. ESTI~. EXPIRES ~ OAYS AFTER DATE. a~ ~ks. a~or drafts m~e paya~e Io Insur~ a~ a~ r~e~s TAX $ .- ..~ (tj ~._
,he~ au~z. ~. as. th..t--ale a~ ha. r.--.a ~ of ~e., ~ta. ,hal th~o. ~ settlemenl f~ Insur.'s ~aim lot ~mages lo the a~ve TOTAL $
~ ~1 ~S ~ ~ ~ ~ this ~. de~ ~hi~e. ~ / ,/'
ADVANCE
X OA~ / / CHARGES
Deductible Potion of All Insurance Claims Must Be Paid Upon Delive~ of Car. GRAND
TOTAL
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