HomeMy WebLinkAboutCC 4 CLAIM #82-25 11-15-82DATE:
TO:
F ROM:
SUBJECT:
November 2,
CONSENT C~T,F. NDAR
NO. 4
11-15-82
1982 Inter-Corn
HONORABLE MAYOR AND CITY COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: E. PAULINE DECARLO
FILED WITH CITY: 9/24/82 CARL WARREN FILE NO. S 32741 RR
D/L: 8/16/82 CLAIM NO. 82-25
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 CITY. ? TUSTIN
('For Damages to Person~ or Personal Property)
U.S. Mail
Inter-office Mail
Over the Counter
via
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 info=~,ation rela-
tive to damage to persons and/or personal property:
1. NAME OF CLAIMANT: ~ .~C,_,~ ~ ~_LC
a. ADDRESS OF CLAIMANT: ~%.~
SOCIAL DRIVERS
d. SECURITY NO: ~ ~ ~ ~ ~£~ A e. LICENSE NO: g ~'~,..~.
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 of Tustin only:
4. Occurrence or event from which the claim arises:
a. DATE: ~-- /~ _~.~ b. 'TIME: ,~,'~ /3/37 c. PLACE (Exact
and specific location):
How and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the injury or damage ~Use additional p@pe~ i~ necessarY).
What particular action by the City, or its employees, caused the
alleged damage or injury?
0
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, stats 'no
injuries". ...... - - .
Give t.h of .the City employee(s) causing the damage or injury
. -
Name and address of any other person injured: ~-~w~_-~--~.-~,&'~~
8. Name and address of the owner of any damaged
Damages claimed: .
a. Amount claimed as of this date:
b. Estimated am~nt of future costs:
c. Total ~ount claimed:
d. Basis for computation of amounts cla~je copies of all bills,
invoices, estimates, etc.:
10. Names and addressees of all witnesses, hospitals, doctors, etc.
C.
d.
.1. Any add.,ition.a,1 informp~ion that might be h.elRf..ul .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 Re 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 CORREC~f.
Executed this ~ day of ~3~r~-~L6- , 19 ~ , at Tustin, California.
Office of the City Clerk,
Tustin, California
C Ai , No: f t-
DATE FILED:
Revised 8/05/81
JGR:se:R:8/5/81 (A)
(~)
{
yOUR tNSu~NCE HAS ~
R~AiN ~18 ~ FOR
WESTERN MEDICAL CENTER ; '
1001 IL TuMht Ave., P.O. Box C-11912 -,_ ;..
Saatal Aha, Ca., Telephone 714-838-3_'t~_~,
THE HOSPITAL IS BILLING AGENT FOR PHYSICIANS RENDERING SELECTED
PROFESSIONAL SERVICES TO HOSPITAL PATIENTS.
SEE REVERSE SIDE FOR PROFESSIONAL SERVICES LISTING.
WESTERN MEDICAL CENTER
DEPARTMENT 0f ,' IERGENCY MEI)ICI t i To.
~ DIAGNOSTIC ;~'~:S OBTAINED THIS V~T.
~ ~A~ Uk ClJL~R[
The e~.~m.tnacion, C=aamaiac and ~.uc,k~ycecacio~ o£ ~c~
co p=o~e co~Laci ~ ~e. A ~ o~ yo~ r~ord
z-=ay ~ o~e= C~Cs ~X be a~$i
~ ~ ~n~ ~= you 1lC ~ check you,
~oc~r ~ you ~T~ ~ ~o~ a ffo~p
Dr. . ~. ,~. ~ ; telephone: ,~ :~ ~- ~ days,
you are unable co ma~a an appoin~nenc wi~h ~he above doctor, please
E~ezg~ncy Depa=~menc [o= assisr, ance.
Emergency Depa~aanC soomer ~han ~he above imdicaca~ appoin~manz r~tme. (The in~arp~a~-
scion o~ you= diagnmsr, tc sCudiea i.e. x-rays, EEC , or cea~s have beaa rendere~ on an
~-~aac? basts.)
~,e~e~be~ char. noaC illnesses ancl ~any ~dicaC~ can ~fecc yo~ ~s. You
a~ ~a ~CiviCi~, ~ y~ are ~C
pcac~C~ p~c~.
SPECT. I~C INSTR.--lIONS:
Please Eo~.o~ i_-~=uccicna on back o~ ct~Ls sheet.
Z hereby acknowledge =acaipc o~ r.ha ~-uccions indicated above. Z ,~,~de~s~nd chaC Z
have Bad emergency C~eaCmmC only and Char. Z may be released be~o~e all of my medical
p=obl--, a~e known or ~ea=edo Z will ar~-ye for follow-up ca=a as ins=ruc=ad above.
Patient
(~aCianC or repcasan~Cive sign)
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Usa ~C or co2d on ~e .~J~ ~ - ~h~er
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2eporc co your doc~r ~c~ ~ you ~ve
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