HomeMy WebLinkAboutCC 4 CLAIM #88-4 05-02-88DATE:
~. 20, 1988
CONSENT CALENDAR
NO. 4
Inter-eom
FAON:
$ U8J ECT:
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.
City Attorney
JGR (F4.se)
Enclosure:
Copy of Claim
CLAIM AGAINST THE C' "OF TUSTIN
(For Damages to Per.~_ ,s or Personal Property)
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 o~
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 t
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
rive to damage to persons and/or personal property:
SOCIAL . DRIVERS '~
d. SECURITY e. r. ICENSE NO:
e
o
Name,. telephone and post office address to which claimant desires notice
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:
The City of Tustin and the following employee(s) of the
City of Tustin only:
Occurrence or event from which the claim arises:
a.
ew
DATE: \\-- q' ~ b. 'TIME: ~.'~O~ c. PLACE (Exact
and specific location): l~Ohi/I .D~.)~ ~-
How and under what circumstances did damage or injury occur? Specif'
the particular occurrence, event, act or omission you claim caused
~e injury or damag~ (Use additional paper if necessary).
What particular action by the City, or its employees, caused the
alleged damage or injury? '. p ,
'5. 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
injuries"
6. Give the name(s_~_) of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured:
Name and addre'ss of the owner of any damaged property:
Damages claimed: '
a. Amount claimed as of this date: 5~'~"'7 ·
b. Estimated amount of future costs:
c. Total amount claimed: 4 ~5 \
d. Basis for computation of amounts claimed (inc~u~.,eI c~op~les of all bills,
invoices, estimates, etc.: '%¢'~_. '~I,.30C'~(!'~
10. Names and addresses of all witnesses, hosp,itals, doctors, etc.:
b,
C.
d.
,1. Any additional information that might be helpful in considering this clai'm:
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE C~IMI (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 5..~ ~_~ ~\~9~. , 19 . , at Tustin, California.
Office of the City Clerk,
-mustin, California
~LAIM NO: ~?'~
Revised 8/05/81
JGR:se:R:8/5/81 (A)
CLAIMANT ' S SIGNATURE
TR~OLLISION REPORT-P.
$55-03 (Rev 12-S4} OP'i 042
rICHECK
SUPPLEWENTAL
SUPPLEMENTS FORM ~
'TRAFFIC COLLISION REPORT
OTHER;
CONTI NUATI~ ONLY
DATE OF ORIGINAL iNCIDENT j TIM,F.
1
MO. D~,Y YR.
LOCATIO,N/SUBJ EC'T
BEAT
' j RE RORTI ',IG DISTRICT
PREPARED 8Y
,E/RANK
NUMBER PREPAREC)
~vlO. DAY YR.
REVIF~/ED%APPROVE D
/ / ./I/~.,.~
BY
o~. ~,~ ~..,. ,'" 1~11'I'~: ~o~, ~.S~E~H'~?' R.o. 3 ~
~- )ST OFFICE BOX I~79
~ . .~-?. ~~ ~ ........
, . ~L . I ': ' ' :':: ' '
..... ._ ~ .... ~ ' ~E .~ ~ ~ -~
/ ~Zo~-z~ "~' 9~ .... .' '4'" " '-" ....
~ . ..~,._ ~ ~/ ~7 ,-...'~ ~m.. ~,, -.'. '..'. -
....... ,~/1 -'~. "-~ ", ',~'"'~.v' · -., "~ ..'~:'
- ~ . - . ..~ .~,.:s;. · ~ . ..... ~:,~,~,'.:,:
,.. ..... .... ,... ,,:. ,:.,~.. -~,,~r~. , ....,..~:~.- ..... ...,..~:,.,,...,.:~...
. . ~~.~.,... ~j": ~ ..... ~x ........ ~,.,.
,.: ..... ......, , ..... .:
/ ' ' }1 ~ ..... ~?' .' ..... uneets~m"t~shmy~nli-t,,ilamo ............ '- ........ ota~ome
~. ~l~[e ~sec~ me amour o re~irs..I agree m.t stor--- -~-- ~ ~[~ m~mc.~ henls ack~wle~gee or
............. .. _... ...
~,"-:'-:.~: ..'~ -'~..;~ ..... z.:- ' 't '~'~ .rr. x. -...~ .... ~:, ..,-.4. · ·" ~.'.
' -'- * ~ ' ..~' '" - ', ..... ' -'t -- ' ' ~' ""' '"~; ' '
.... ,. ,_.. ,. .~.. , _ .. a . -. . ~:; · , .,
_ ,.:~i '.~ '7, ~ .:. ~?.~
...... '-. ~"~' Z-' · Z.r .~.. -~ . _.".~';:. '~-..:-"'-
....... . . -----..: :. .( ..-
N:.' TOTAL P~R~J ~ ' ~" :"' /"~// ' // '
... ..-,::.~ .... .- ~ ~:,.: -., ~ .... ~.--
The undemlgned,:~eminafler ~lled "lnl~rld" lot t~e ~ '" '"" -" COMMENTS ' 'BODY SHOP SALES AND SERVICE
~,~:~.'o ~ ~
~ 4'~2. ~ .'-
D~U~E~MOU~ M~TBE PAID~iME ~H
Uon by ~nla Anl Detlun, Irl~.'d~el hereby granlr'to-~ant& Aha De.un, - -'"" , .-* . BODY SHOP
_- . ~ .. :~:- :~., .. .... ~ . - . . ~:. ~ ". , . .