HomeMy WebLinkAboutCC 10 CLAIM #88-19 06-06-88CONSENT CALENDAR
NO. 10
6-6-88
'Inter-Corn
SUSJ ECT:
HONOPJ%BLE MAYOR AND CITY COUNCIL
CITY ATTORNEY
CLAIMANT: O'DAY, MADELINE; D/L: 2/10/88; DATE FILED
W/CITY= 3/9/88; CLAIM NO: 88-19; CARL WARREN FILE
NO= S54579PRS
After investigation and review it is recommended that the above-
referenced claim be rejected and the C~ty Clerk directed to give
proger notice of the rejection to the claimant and to the
· claimant's attorney.
MAS L. WOODRUFF
Assistant City Attorney
JGR(F4.se)
Enclosure:
CoDy of Claim
-~LAIM AGAINST THE CIT~' ,F,TUSTIN
('For Damages to Person_ or Personal Property)
Received by ~ via
U.S. Mail
Inter-office Ma'
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 th
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
tire to damage to persons and/or personal property:
1. NAME OF CLAIMANT: ~
a. ADDRESS .OF CLAIMANT. ~
b. PHONE NO. (?/~')~' ? c. D]%TE OF/BIRTH: ~ ~_~-
SOC Ar. ' ' ' DRIVSRS '
d. SECURITY NO: /. e:L CENSE NO: ? ,
2. Name,. telephone and post office address to which claimant desires notices
to be sent, if other than above:
e
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. DATE: ~-/~--~" b. 'TIME: /J: /~-- c. PLACE (Exact
d. How and under what circumstances did damage o~i~jury occur~ Specify
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper if necessary).
ee
What particular action by the City, or its employees, caused the
alleged damage or injury?
®
Give a description of ,.~e injury, property damage r loss so far as is
known'at the time of this claim. If there w.ere no injuries, state "no
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:
®
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 eoPies of all bills,
invoices, estimates, etc.:
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
ao
de
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 A~D CORRECT..
Executed this ~g,D~--day of ~7-~L/~L.?~ , 19 ~' , at Tustin, California.
' ' ' CLAIMANT ' $ $IGNAT/~RE
Office of the City Clerk,
T in, California -
Revised 8/05/81
JGR:se:R:8/5/81 (A)
6
11
14
15
17
18
3~ln Ave.
KEEP THIS SLIP FOR REFERENCE
5H280; ~--D~-'~-"~'I®
~.R. NO, AB*6628-N
YR.&MAKE - - ..
-;.~:.,.:TUSTIN, CA 92680' ' -' '-
PHONE (714) 731-0990
PAYS$ ' ' ADJ.
PHONE
MODEL BODY STYLE LICENSE -
,,,,.- MOT OR
. ¢a~e. oHire. ~helt ~,accide~t m' a~y otter cause ~yo~l~r coMrol.
& PAINT
REMARKS:
- (llet) PART~"
PAINT MArL
SUBLET NET..
~{ ~.sALES TAx
ESTIMATE TOTAL '; ' '
Adv. Charges' ' .
(S) Sub~L (~) ~ch~ge
(U) U~. (R) R~Ot. ~