HomeMy WebLinkAboutCC 4 CLAIM #85-36 10-21-85 CONSENT- CALENDAR
NO.
10-21-85
Inter-Corn
TO:
HONORABLE MAYOR AND CITY COUNCIL
FROM:
JAMES G. ROURKE, CITY ATTORNEY
SUBJECT:
CLAIMANT: SANTANAS, GABRIEL & SANDRA; D/L: 04/28/85;
DATE FILED W/CITY: 08/02/85; CLAIM NO: 85-36; CARL
WARREN FILE NO: S-43075 LFH
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.
JGR (F 4. se )
Enclosure:
Copy of Claim
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$
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5
7
8
10 Date:
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15
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18
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20
2,1
2,2
£4
25
27
28
RECEIVED
· city Coun=iX
City of Tustin
~s~in, California
This claim was due on August 16, 1985 but due to late
arrival of medical bills and a vacation absence, I am filing
this. claim today and request a two-day .relief from default'.
[STER CRUZ GONZ~LES
1218 S. Sullivan
Santa Aha, CA 92704
(714) 557-9809
'CLAIM AGAINST THE CITY OF TUSTIN
('For Damages to Persons or Personal Property)
Received by
U.S. Mail
Inter-office Mail
Over the Counter
via
The law provides generally that a ciaim must De ~lled wlt~ the City Clerk o=
the City of Tustin within 100 days after which the.incident or event occurre(
Be sure your claim is against th~ 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 t2
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 re!
' tire to damage to persons and/or personal, property:
1. NAME OF CLAIMANT: Este~ C. Gonzale$
a. ADDRESS OF CLAIMANT:
b. PHONE NO: ( c. DATE OF BIRTH:
SOCIAL DRIVERS
d. SECURITY NO: e. LICENSE NO:
2. Name, telephone and post office address to which claimant desires notice
to be sent, if other than above:
This claim is submitted against:
a. X 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: 5-8-85 b. 'TIME: app~0x. 9:45 AM c. PLACE (Exact
and specific location): 15662 "B" St.? Tustin; CA 92680
d. Bow and under what circumstances did damage or injury occur? Speci~
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper if necessary).
Walkinq from sidewalk ~ ~treet. steooed in a concealed hole at the curb
e. 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"
Hurt foot '(see attached medical form)
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: $399.55
a. Amount claimed as of this date:
b. Estimated amount of future costs: Unknown at this tin
c. Total amount claimed:
d. Basis for computation o~ amounts claimed (lnclude copies of all ~ilis,
invoices, estimates, etc.: See attached
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
a. ~ Att~ahPd
b.
0.
11. Any additional information that might be helpful in considering this claim:
~njury is still painful, requires ultrasound.
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 ~ 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. tru6
I cer.tify under penalty of pe=jury that the foregoing is TRUE AND CORRECT.
Executed this 20th day of August , 19 85 , at Tustin, California.
Office of the City Clerk,
Tustin, California
CLATM NO: ~-' 3~
Revised 8/05/81
JGR:se:R:8/5/81 (A)
CLAIMANT ' S~ SIGNATU~
ESTER C. GONZALES
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t~ ~u~- ~, ~ly,: tt2{ ~t ~ f~ thi{ offl~ to {d{ OUt the {~ ~
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K-gQ2~-~idy'~t/i vi~ts~.~..,'~-~:~,~. ~ C-IOi 16 SMA ~2
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MATTHEW W. SZ~WL. OWSKI, M.I~1. '.
1 1 1 S0 Warner A~. · Suite 1 S1
FOUNTAIN VALLEY, CA.
F~one: 540-0511. ·
453';!3'
..... your insurance claim form-,."
C)~l.. L. IC. -G$020 '
MATTHEW VV. SZAWLOWS~I. M.D..,:~;
11180'W=irnm' Aw. ~ ,~ite 1S 1 ' "
FOUNTAIN VALLEY, C,K. g270~
your insurance claim form.
This Itlt~t c~fltmiml MI the
I~ r~ = f~-thll off~ to fill out t~
I-to your imun,ce claim'
This flet~t ~ofltliN Ill
f~ Thi~ offi~ to fill out the ,~
NAM[
· .~ :~:,:'.~.~.~ .:.: ~ ~:~,;:.½.:~ :., '.
~gfleO:' ' " .... · ' Date
ISEt,
Mercy General Hospital ,00 -
~.o. Box ~9~2 , ~ 0
Manna ~1 ~ev, ~ ~2~
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tZ,&~E-~¢.;:ES.TE~.CRUZ,.~,, .... .:~-? . "MERCY 65NER~L HCSFIT&L 2C 20 6g .05/15/85
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