HomeMy WebLinkAboutCC 5 CLAIM #82-12 06-07-82DATE:
TO:
FROM:
SUBJECT:
May 13, 1982
CONSENT CALENDAR
No. 5
6-7-82
Inter-Corn
HONORABLE MAYOR AND CITY COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: GILBERT, BARBARA JO
D/L: 1/2/82 FILED W/CITY: 4/9/82
CLAIM NO: 82-12 CARL WARREN FILE NO: 31613 RR
After investigation and review it is recommended
that the above-referenced claim be denied and the City Clerk
directed to give proper notice of the denial to the claimant
and to the claimant's attorney.
JGR:se
Enclosure
1. Copy of Claim
cc: OCCRMA
CLAIM AGAINST THE CIT~F TUSTIN
('For Damages to Persons or Personal Property)
Received by ~ ~. ~-~ via
U.S. Mail
RECEIYED -
1982
Clt~ Clerk
Inter-office Mail B~ ~ ~
Over the Counter ~ ~ ~
The law provides generally that a claim must be filed with the City Clerk of
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:
a. ADDRESS OF CLAIMANT: ~ ~,/~ /,~,~q. ~W~ /~//~//~z'~, ~/;/~]. F=2$'OY'
b. PHONE NO: (~/g) ~g~-~'~ ~-~.~
SOCIAL DRIERS
d. SECURITY NO: ~ &~-~/ e. LICENSE NO: ~
2. Name, telephone and post office address to which claimant desires notices
to be sent, if other than above:
This claim is submitted against:
a. The City of Tustin only.
b. The following employee(s) of the City of Tustin only:
The City of Tustin and the following employee(s) of the
City o.f. Tustin only:
Occurrence or event from which the claim arises:
a. DATE: ,/-~-?-~ b. 'TIME: g;$o~;.M SF~z~K. c. PLACE (Exact
and specific location):
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 hecessary).
e. 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, state "no
injuries".,~ .
6. Give th.e, name(g) of t.he City employee(s) c~ausing ,the damage~or injury:
7. Name an~ a~ress on any other person injure~:
8. Name and ad~Eess..of the owner of an~ damaged property:
9.. ~mage~ claimed:
a. ~ount claimed as o~ this date:
b. Estimated amount of future costs:
c.. Total amount claimed ~ .
d. Basis for com~tation o~ amounts cla~med (lnc~de copies oE. all bills,
invoices, estimates, e~c.: ~a~ ~ ~ ~/~
10.. Names and; addresses o~ all witnesses, hospitals, doctors, etc.:
d.
Any additional information that might be helpful in.considering this~ claim=
WARNING: I~ IS A CRIMINAL OFFENS~ TO' FILE A FALSE'. CLAIM'.
Section 72; InsUrance Code Section 556.0)
(Penal Code
I have read the matters and-statements made in the above claim and I know the
same to be true o~ my' own knowledge~ except as. to those matters stated to be
upon information o= belie~ and as to such matters I believe the same to be true.
I certify under penalty o~ perjury that the foregoing is TRUE AND CORRECt..
Office of the City Clerk,
Tustin, California.
Revised 8/05/81
JGR:se:R:8/5/81 (A) ~
TU.STLN POL]jCE DEPT.
m.u.L ^aa~ST
TUSTIN
POLICE- DEPARTMENT
FOLLOW-UP REPORT []
RD
CONTtNUATION REPORT ~
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INCIDENT REPORT
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TUSTIN
POLICE DEPARTMENT
FOLLOW-UP REPORT []
RD
CONTINUATION REPORT ~
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