HomeMy WebLinkAboutCC 3 CLAIM #86-43 11-03-86CONSENT CALENDAR
NO. 3
11-3-86
DATE:
Inter-Corn
October 15, 1986
FROH:
SUBJECT:
HONORABLE MAYOR AND CITY COUNCIL/
CITY ATTORNEY
NO: 49179CVH
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.
di~y Attorney
JGR (F4. se)
Enclosure:
Copy of Claim
CLAIM AGAINST THE CITY _~ TUSTIN
(For Damages to Persons or Personal Property)
Received by via
U.S. Mai'l
Inter-office Mail
Over the Counter
The law provides generally that a claim must De filed w~th the City Clerk o~
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 and/or personal property:
e
.3.
a. ADDRESS OF CLAIMANT:
b. PHONE NO: (
SOCIAL
d. SECURITY NO:
c. DATE OF BIRTH:
DRIVERS
e. LICENSE NO:
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:
Ce
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: /~ ~_~,~ c. PLACE (Exact
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)..
What particular action by the City, or its employees, caused the
alleged damage or injury?
'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"~ ~/ 3~-/3 ~
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 bills,
invoices, estimates, etc.:
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
a.
b.
\,
d.
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 info=marion 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 ~8~/;- , 19 f~' , at Tustin, California.
Office of the City Clerk,
Tustin, California
CLAIM NO: ~
' S ~GNAT URE
Revised 8/05/81
JGR:se:R:8/5/81 (A)
0
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