HomeMy WebLinkAboutCC 6 CLAIM #82-14 06-07-82DATE:
TI):
FROM:
SUBJECT:
May 12, 1982
CONSENT
6-7-82
Inter-Corn
HONORABLE MAYOR AND CITY COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: DAVIS, Arthur L. D/L: 4/21/82
FILED W/CITY: 4/23/82 CLAIM NO: 82-14
CARL WARREN FILE NO: 31710 AB
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
dLAIM AGAINST THE CIT~F TUSTIN ~ -
('For Damages' to Person~"~ Personal Property)
Received by via
U.S. Mail
Inter-office Mail
Over the Counter
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 occurred.
Be sure-you= 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:J
The undersigned respectfully submits the following claim and information rela-
tive to damage to persons and/or personal property:
SOCI~ DRI~RS~
Name, telephone and-post office address to which claimant desires notices
to be sent,, if other than above:.
This claim is-submitted against:
The Cit!r of TUstin~ only.
The following-'employee (s) of the- City' of .Tustin
The City of Tusti~ and the following employee(s) of the
City'of Tustin onlyr
4... Occurrence o= event from: which th~ claim arises:
a. DATE~ A/-~/-~ b. 'TIME:~ ~:.~dg ~o/~ c'. PLACE (Exact
and specific location):
d. 5ow and under what circumstances did damage or injury occur? Specify
the pa~cicular occurrence, event, act or omission you claim caused
the injury' or damage (Use additionai paper~ if necessary).
e.~ What particular action by the City, or its' employees, caused the
allege~ 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 the name(s) of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured:
8. Name an~ address, of the owner~ of any damaged' property:.
Damage~ claimed:
~L.
b.
d,
Amount claimed a~ o~ thi~ daEe: ~ / ~/3. o~
Estimated amount of future costs:
Total amount claimed~.
Basis for computation, o~ amoumt~ claime~l (include copies~ of al/ bills,
invoices, estimates~ et~.: _~--- ~.
Name~ and addresses of all ~itnesses, hospitals, doctors, etc..:
d.
Any' additional_ information that migh~ be helpf=L ir~ considering thi~ claimr
WARNING:. IT IS A CR/~INAL. OEEENS~ TO ~ILE A FALSE. CLAIM: (Penal Code
S~tion 72; Insurance Code Section 556.0)
I have read the matters and, statements made i~ the abov~ claim an~ ~ kno~ the
same to be true of my owmknowledge~ except as to those, matters state~ to be
upon information_ o= belief and as to. such matters L believe %he same to-be true,
I certify under pen~l~ o~ perjur~ that the foregoing is TRUE AND CORPd~C~.
7
Executed. thi~ ~.~ .. da~ off Apr/ , 19 ~2 , at Tustin, C~!ifor~ia.
Office of the City' Clerk,
Tustin, California
CLAI~{AN~J S SIGNATURE
Revised 8/05/81
JGR:serR:8/5/8'L (A)
.~ NTA ANA DODGE INC,
Phone (71~) 835-3691
1401 Nor~hTustin Avenue
SANTA ANA, CALIFORNIA 92701
4X
6
7
8
ESTIMATE OF. ~AmS ~
10
11
12
13
14
15
16
17
18
19
21
24~
(net) PARTS
PAINT MM'L
SUBLET NET
BODY MAT'L
Stor.~ge ~.111 be cherged 4~ hour~ if~er vehicle en~ our ~emlm, or
,2 o
/-0
,.2. ,~ d
All Par'cs ~, unle.
ADDITIONAL Work OK'd ~ ................................ ~ ............................... (~ ~) ' (U) U~, (R) R~ullt,
~ ................................... ~ ~m ~ ....................... ~NT. ............................... ~EN ITE~
JUN~D, unle~ ~ ~ Return of Pa~* w~n of~ · pla~, ~ ~a~ ~
thereto, i he.by wl~l ~ Sta~e ~ Um~ti~ and ff ~ ~ on this a~
empi~lnl ~( an aflo~q I a~e to ~y Jt~% intl~ ~r month. ~ ~ ann~ INSU~NCE O~D~TI6~
~r~n~le rate of 18% fr~ ~te. ma~abM aUome~s IH a~ ~0~ ~l. PAiD ~FORE CAR l$ RE~ASED. ~ES T~
(~r/~t} By ...................................................................... ~te .............................. ~~~~t A~. Ch~
~TAL $
INCIDENT REI;'ORI" ~
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ltlSTIN
IN3LIC~ DEPARTMENT
FOLLOW-UP REPORT [] CONTINIJATIGN IIEIK)RT
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