HomeMy WebLinkAboutCC 4 CLAIM #86-18 05-19-86HONORABLE MAYOR AND CITY COUNCIL/
FROM: CITY ATTORNEY'S OFFTCE
CLAIMANT: J. STUPY, M.D.; D/L: 4/3/86; DATE FILED
W/CITY: 4/21/86; f~r. AIM NO: 86-18; CARL WARREN FILE NO:
4s961cv-
S UBJ 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.
JGR (F4. se)
Encl osur e:
Copy of Claim
'CLAIM AGAINST THE CITY..F TUSTIN
(For Damages to Pers¢C ~ or Personal Property)
Received by
U.S. Mail
Inter-offi6e Mail
Over the Counter
via
The law provides generally that a claim must' be filed with the City Clerk ~
the City of Tustin within 100 days after which the incident or event occurr.
Be sure your claim is against the City of Tustin, not another public entity
Where space is insufficient, please use additional paper and identify infor~
tion by paragraph number. Completed claims must be mailed or delivered to
City Clerk, The City of Tustin, 300 Centennial Way, Tustin, California 9268
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:
~. '~.,~ o~- c~,~: . J, ~w~/~'( ~. ~, ~'~/, .
a. ADDRESS OF CLAIMANT. ! .
b. PHONE NO: ( ~. DATE OF BIRTH:
SOCIAL ~ ' - DRIVERS
2. Name, telephone and post office address to which claimant desires notic
to be sent, if other than above:
/F~
¸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 Tustin only:
Occurrence or event from which the claim arises:
d. }{ow and under what circumstances did damage or injury occur? Spec~
the particular occurrence, event, act or omission you claim caused
e. What particular act'ion by the City, or its employees, caused the
alleged(damage or injury? ~ ,_/ / M~ ~- ~ ~. i
~~,~,~,, ~ -- ~ ~,--~ _~_,
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'. ,
m
Give the name(s) of the City employee(s) causing the damage or injury:
Name and address of any other person injured: . ~./'.~/~_./
8. Nam~ an~ address of the owner of ~ny damage~ 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 itnesses, hospitals, doctors, etc.:
a.
b.
c.
d.
.1. 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 t.o be true.
I certify under penalty of perjury tha~ the foregoing is TRUE AND cORRECT.
Executed this /~w day of ~ , 19 ~ , at Tustin, California.
Office of the City Clerk,
latin, California
CLAIM NO: ~
DATE FILED:
Revised 8/05/81
JGR:se :R: 8/5/81 (A)