HomeMy WebLinkAboutCC 9 CLAIM #83-20 06-20-83DATE:
FROM:
SUBJECT:
6/7/83
CONSENT CALENDi%R
No. 9
6-20-83
Inter-Corn
~N~'RABLE AND CITY
MAYOR
COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: CAL-FARM/FISHER; D/L: 12-30-82; FILED W/CITY:
5-12-83; CLAIM NO: 83-20; CARL WARREN FILE NO: S 34804
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:se
Enclosure
1. Copy of Claim
cc: OCCRMA
· ~LAIM AGAINST THE CIT OF TUSTIN
~For Damages to Person. or Personal Property)
Received by
u.s. Mail
Inter-office Mail
Over the Counter
via
The law provides generally that a claim must be filed with the City Clerk cf
the City of Tustin within 100 days after which the incident or event occurs-ed.
Be sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify infoama-.
tion by paragraph number. Completed claims must be mailed o~ delivered to the
City Clerk, The City of Tustin, 300 Centennial Way, Tustin, California 926E0
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits 'the ~ollowing claim and information rela-
tive to damage to persons and/or personal property:
NAME OF CLAIMANT: $lilliam }l. Fisher
a. ADDRESS OF CLAIMANT:
2. Name, telephone and post office address to which claimant desires notices
to be sent, if other than above:'
This claim is submitted against':. City of /ustin
a. XXX The City of Tustin only. '.'lATER DEPARTI.~E~.~I
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:
Occurrence or event from which the claim arises:
a. DATE: ]2/30/82 b. 'TIME: c. PLACE (Exact
and specific location): l~? q~,~t~t q~n .]uan'St. Tustin, CA 92680
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)·
see attached photocopy
What particular action by the City, or its employees, caused the
alleged damage or injury? ' ·
see above
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 and address of the owner of any damaged property:
9. Damages claimed:
a. Amount claimed as of this date:
Estimated amount of future costs:
c. Total amount claimed:
d. Basis for computation of amounts claimed (include copies of all bills,
invoices, estimates· etc.:
10. Names and addresse~ of all witnesses, hospitals, doctors, etc.:
a.
b.
co
d.
!1. Any additional information that might be helpful in considering this cLai~:
WARNING:
IT IS A CRIMINAL OFFENSE 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 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
Revised 8/05/81
JGR:se:R:8/5/81 (A)
CLAIMANT ' S SIGNATURE