HomeMy WebLinkAboutCC 7 CLAIM #83-34 03-19-84 ~ CONSENT CALENDAR
\~/ ! nter - C om
OAT£:
03/12/84
TO:
FROH:
SUBJECT:
NORABLE MAYOR AND CITY COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: MOORE, ELIZABETH; D/L: 6/17/83; DATE FILED
W/CITY: 9/23/83; CLAIM NO: 83-34; CARL WARREN FILE
~35979SK
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)
Enclosure:
Copy of Claim
cc: OCCRMA
· '~LkIM AGAINST THE'CIt 3F TUSTIN
(For Damages to Persons or Personal Property)
Received by via
U.S. Mail
Inter-office Mail
Over the Counter
The law provides generally that a claim must De filed wlth the City Cler~ oi
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 9268q
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:
1. NAME OF CLAIMANT: ~;i~+4~
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 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:
c. The City of Tustin and the following employee(s) of the
City of Tustin only:
4e
Occurrence or event from which the claim arises:
a. DATE: ~-;7- ~ b. 'TIME: ~' 7 ~- c. PLACE (Exact
and specific location): P~,A'- h~+' /',~/,~...~,,,.,~ /:'~.k~ ~u~;~
d. HOW and under what circ~stances 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).
ee
What particular action by the City, or its employees, caused the
alleged damage or injury?
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, s%ate "no
injuries". .
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: ~ ~.~u ~% . GO
d. Basis for computation of amounts claimed (include copies of all bills,
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
b.
C.
d.
11. Any additional infor~atiOn that might be h~lpful in considerin~ 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 AND CORRECT.
Executed this ~ day of ~¢~+~.~ , 19 ~ , at Tustin, California.
Office of the City Clerk,
Tustin, California
CLAIM NO: f~'~
~ - CLAI~fANT ' S SIGNATURE
Revised 8/05/81
JGR:se:R:8/5/81 (A)
__ .____ _____P~-~.ISiONCOACHWORKS, INC.
ROCKY'S
300 so. S~',~NO,~D, s,~mA,~,,~, C,~., ,~2~0~
714 / 835-2185
STATE LIC. #AM-83458
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Re~air
Insurance Co Phone Order No
Retain [] Customer IniUal
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