HomeMy WebLinkAboutCC 4 CLAIM #86-58 02-02-87 CONSENT CALENDAR
Inter-Corn
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM:
CITY ATTORNEY
SUBJECT:
CLAIMANT: JACQUELINE M. ANDERSON; D/L:
FILED-W/CITY: 12/29/86; CLAIM NO: 86-58;
FILE NO:
9/19/86; DATE
CARL WARREN
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 rejectionclaim~ntto the and to the
claimant's attorney. ~ ~
JA.V G. ROgRKE
Cify
Attorney
JGR (F4. se)
Enclosure:
Copy of Claim
('For Damages to Persons or Personal Progerty)
the Counter%.~.:
over ~ ~; ..... ~-:' ~ - . .... .. :.
The law provides generally that a claim must be ~iled with the City Clerk
the citY of Tustin within '100 da~s afte~ which the inciden~ or.' event occurred."
Be sure your claim is against =he City of Tustin, not another public entity.
Where space is insufficient, please use a~ditional paper and identify informa-
tion by paragraph number. Completed 'claims must be mailed or delivered to the
City. Clerk, The Cit~ of Tust~n, 300 Centennial Wa~, Tustin, California' 92680 .'
TO THE HONO~LE:MAYOR ~D CITY COUNCIL, City of Tustin, California:
b. PHONE NO: (~/ c. DATE OF BIRTH:
d. SECURITY NO: ~ e. LICENSE NO= " .,
-~ -..- :2. · ~f3i '~ : ''~
2. Name,' %elephone and po~t office address to which claimant desires notices
to be'sent, if,other than above:
· .3.
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 Tusti~ only: . .
4. Occurrence or event from which the claim arises:
and s~cific_location): po[, f
How and under wha'~ circumstances, di~ damage "o= injury occur? Specify
the particular occurrence, event, act or omission.you claim caused.
the injury br ~amage (Use a~di~ional paper if ~cessary).
e. What particular action by the City, or its employees, caused the
-;' a%leged damage or. injury%
'Sz~.,.Give a. desC~ipt~0n of the,..injury, property damage or. 1ossa. so:far as is ....
';~ known at the time of ~his?claim. If there were nO injuries,~(s~te='no
7. Name an~ a~dreS~°f any other person injure~: t'
., 8.' Name and add~S's?~°f the 'OWner of any d~maged pro~rty :,~ ......... · -. -, .....
4[?- ;' ':: ":~'":-?~':~":: ''~' " ~'"~' ' ':: ':"'"~>:" :
C. Total ~oun= claimed=.- , '- -
~ ~.-Basis for c~tation-~of, am~nts claimed (incZude cogies o~ all bills,
invoices, estimates, etc.=
10. Name~ and addresses of ail witnesses, ~ospitals, doctors~ etc.: ~ ·
11';: ~y a~i=i6~a~~'info~ati6n~ ~ha=' might be helpful in'considering =his claim:.,
WARNING: 1T IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM: (Penal Code
Section 72; Insurance Code Section 556.0)
. -..:-..: :.~:.~%~:~.,J,'~'~:;-. ~ ~.. .'-" . .
I-. nave. read', the. smatters':- and~statemen2g:'made'- in the above' claim and I know the ..,.~ -.
same--t~5--b'e-true'~ofJmy own knowledges' except~'as~to-~hose mat~ers~ st-at'~'d' t6-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 ~his~'!:I~"~ d~y of-!.i.'~~~ ~xW~, 19 ~ , at'Tu's in, California.
',...' ' .... '
Office of the City Clerk,
Tustin, California ~'.:
Revised 8/05/81
JGR:se :R:8/5/81 (A)-).
CLAIMANT ' S SIGNATURE