HomeMy WebLinkAboutCC 4 CLAIM #81-1 04-06-81DATE: 3/18/81
CONSENT CAL~TDAR
No. 4
4-6-81
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~: HONORABLE MAYOR AND CITY ~OUNCIL
FROM: JA.~IES G. ROURKE, CITY ATTQRNEY
5UBd££T: HARRY M. STOCKWELL, JR.; CLAIM NO. 81-1; DATE OF LOSS: 11/16/80;
DATE FILED W/CITY: 1/5/81
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. Claim of
Harry M. Stockwell, Jr.
',' , · CLAIM AGAINST THE C~]~,y OF TUSTIN
(For Damages to Persons ori__ rsonal Property)
U.S. Mail
Ir~er-office Mail
£ :r the Counter
via
Clerk's Time
J.q;'t 5 1981
The law provides generally that a claim must be filed with
C!:.ce-yuSt;p. City Ck;rk
the City Cler~ of the...City
of Tustin within 10O days after which the incident or event occurred. Be sure your claim is agains: the
City of Tustin~ not another public entity. Where space is insufficient, please use additional paper and
identify information 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
_perscns end/or personal property.-
L NAME OF- CLA[MANT=
a. ADDRESS OF CLAIMANT:
the following claim and information relative to damage to
b. PHONE NO: ( ~ (~ c. DATE OF BIRTH:
d.' SOCIAL SECURITY NO:
e. DRiVEF~'S LICENSE NO: /
Occu~ence or even~ f~m which the claim arises;
a. DATE: /'! ~ [.~ ~ D b. TI~E:
d.
~: ,~ ,."t£/~ c. PLACE (exact and specific
How and.under what circumstances did damage or injury occur? Specify the particula~
occurrence~ event, act or omission you claim caused Lhe injury or damage (use addJ'.ione]
paper if necessary).
.
What particular' action by
injury?
the City,
'"
,o~ r Iq O I
or its employees, caused ~:he all'ged damage or
Nam-% telephone and p~st office address to which claimant desires notices to be sent, if other
n above:
Give a description of(~'e injury, property damage or loC so far as is known at theo tilme ~
thi~ chi.re. If there We~ no injuries, state "no injuries". ' " I.
Give the name(s) of the City employee(s) causing the damage or injury:
Name and address of any other person injured:
Name and address of the owner of any damaged property:
Damages claimed:
Amount claimed as of this date:
Estimated amount of future costs:
To[al amount claimed: '
Basis for computation of amounts claimed (include copies of all bilts, invoices, estimate-·
I
Names ~nd addresses of all witness~ hospitals~ doctors, etc,
a. - /ge~ ~
b.
10.
- Any a55iZ]onal infozraa~ion that might be helpful in considering this claim:
/
WARNING:
IT !S A CRIMINAL OFFENSE TO FILE A FALSE CLAINI! (Penal Code Section 72;
Insurance Code Section
! have read the matters and statements made in the above claim and ! know the same to be true of rr
own knowledge~ excep~ as to those matters slated to be upon information or belief as to such matters
believe the same to be true.
CORRECT.
Executed this ~ day of
Office of the City Clerk,
-'ustin~ California
CLAIM NO. Z'/-: /
I certify under penalty of perjury that the foregoing is TRUE
,1,9 ,<~ / ,at ~~L ,California.
." ~ · 'Claimant's 5igoa~ura . ,.
DATE FILED: /~ ;~"- g/ . '
3GR:se:O:2/SlSO
T/Claim Form D:ll
2001 E. SEVENFEENTH ST. · {714) 558-781!
P. O. BOX 10079, SANTA Al%A, CAL. 927! 1
PARTS PRI~S ban ~n Standard C~ta~xue. & Pdc~ CHABGES WIT~ NOTI~
~ C~y~ ma~ ~ mdd~ ~o~ s~sl I~ nol a~lab~ ~ ~ PARTS
M1u~ wUl ~ dd~ ~ ~r empl~o to. ma~ r~uh~ t~ at my ~ ~ ex~
mec~ 's I;en ~ hete~ a~ ~ e~ ~hi~l to ~i the imam
here~ wlT~ t~ Sh~te ~ Umltit~s and if any m~l~ ~ th]s a~nt ~u;~
r~n~gm rail of 18~ f~ dmt~, fea~abl~ a~om~s f~ a~ ~
I
INSU~NCE DED~TIB~ HUST 1~
PAID BEFORE CAR IS RELEASE~.
SUB~T NET
EST 1 I"RTE TOTAL
Adv. Charges
?/
7440 East Firestone Boulevard
Phone 862-1181
DOWNEY, CALIFORNIA 90241
INSUREO PAYS $ INS. CO. PAYS R.O. No.
)BILE INC., OOWN~-Y. CALIF. IS HEREBY GIVEN·
FO~ YOUR CONVENIENCE, LOW COST RENTAL. CARS AVAILABLE
~,~,--,,~.-,'*~ == mr~t3'r~r~kl ~M R! I IMc:I I~&~t':.l:: ~.1 AIMR MIIRT R~ PAID BY CASH ONLY UPON DELIVERY
TOTAL~
Parts
Sublet
TOW & ADV. CHARGES
GRAND TOTAL $~'~
C
INCIDENT REPORT
I
TUSTIN
POLICE DEP. ART~ENT
FOLLOW-UP REPORT [~ CONTINUATION REPORT
%3
18
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