HomeMy WebLinkAboutCC 3 CLAIM #82-31 10-05-83DATE:
9/8/83
CONSENT CAYRNDAR
NOg 3
· 10-5-83
Inter-Corn
FROM:
SUBdECT:
W/CITY:
uniFY{t%] L~ -~k%~OR ~'*NB~ CITY~0UNC I L
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: ELLIOTT, ONNOLEE; D/L: 11-10-82; DATE FILED
12-20-82; CLAIM NO: 82-31; CARL WARREN FILE NO: S 33389
After investigation and review it is recommended that the above-
referenced claim be rejected and the City Clerk directed to give
proDer notice of the rejection to the claimant and to the
claimant's attorney.
JGR(F4. se )
Enclosure:
Copy of Claim
cc: OCCRMA
f.CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Perso~':~or Personal Property)
Received by via
Inter-office Mail
Over the Counter
The law provides generally that a claim must De 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:
b. PHONE NO: (~ ~&_~/ c. DATE OF BIRTH:
SOCIAL DRIERS
Name, telephone and post office address to which claimant 4esires notices
to be sent, if o~er than above:
3. This claim is submitted against:
The City of. Tustin only.
The following employee(s) of the City of Tusti~ 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: .;om,u~8~'~= b. 'TIME: ~oom c. PLACE (Exact
and specific location):
d. 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 paper if necessary).
ee
What particular action by the City, or its employees, caused the
alleged damage or injury?
Give a description of~ a injury, property damage.r' ' loss so far as is
known at the time of this claim. If there were no .njuries, state "no
injuries".
Give the name(s) of tn. City employee(s) causing the damage or injury:
Name and address of any other person injured: u~
8. Name and address of the owner of any. damaged property: ~.~e,,o~
D~mages claimed:
a. Amount claime~ as of this date:
b. Estimated amount of future cos~a~
c.
d.
Total amount claimed:
-Basis for computation of'amounts claimed (include copies of all bills,
invoices, estimates, etc.:
Names and addresses of all witnesses, hospitals· doctors, etc.:
a.
b.
d.
ll. 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 ~rue of. my own knowledge, except as to ~hose matters s~ated to be
upon information or belief and as to such matters I believe the same to be true.
_---- -- -~ -- ~ ! ~he foregoing is TRUE AND CORRECT.
Executed this . ~ day of D~¢~
· 19~ , at Tustin, California.
Office of the City Clerk,
Tustin, California
CLAIM NO:
CLAI~/~T ' $ SIGNATURE
DATE FILED:
Revised 8/05/81
.~R:se:a:8/5/81 (A)
GUARANTY CHEVROLET
g, NT& ~ ~ 1~II
Il 1,~1 17~,-, 1711
.siey ~ Did. AmL __ Date of loss
fepee~dent Adj. Addruss
E~TIMATE OF flEPAIR COSTS
~Pt. ACE REPAIR
Uc ~
OAT"=
MILES
PAHTS MIS~.
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17'/
TOTALS
I I~r?~ rin~nKI from f~'l will be junkid unlm othcrwifl inttructKI in writ#~.
OR INFORMATION ASK FOR
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BODY tABOR
TOTAL PARTS
I()IAL MR;C.
MECH. tABOR
SALES TAX
E[TIMATE TOTAL
ADVANCE CHARGES
~iI~NO TOTAL
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