HomeMy WebLinkAboutCC 4 CLAIM #80-21 12-01-80DATE:
TO:
FROM:
SUBJECT:
11/7/80 ~ ~.~'~ ~
HONORABLE MAYOR AND CITY COUNCIL
CONSENT CAf,RNDAR
No. 4
12~-1~80
JAMES G. ROURKE, CITY ATTORNEY
CLAIM OF
8-14-80;
CAPITAL WESTWARD; CLAIM #80-21; DATE OF LOSS:
CLAIM FILED WITH CITY: 10-16-80
After investigation and review, it is recommended that the above-referenced claim
be denied and the City Clerk is directed to give proper notice of the denial to the
claimant and his attorney.
3GR:se
Enclosure "
1. Claim of CapitaI Westward
"~ .... _(~LAih4 AC, Ali,lb I I t tL
(Foz Damages to Persons o ~'prsonal Property)~
~eceived By via Clerk's Time Stamp
u.s. !
I~c~-office Maii
( :r the Counter
The law provld~s 9en~rally that a claim must b~ filed with the City Clerk of the ~ity
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 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 the followir;g claim and information
- persons and/or personal property: . ~_ · ,
a. ADDRESS OF CLAIMANV T: 77//7 ~
b. PHONE NO: (~I3) ( ~'C~/'t~5~- e. DATE OF BIRTH:
d, SOCIAL SECURITY NO:
e. DRIVE~% LICENSE NO:
relative
to damage to
" Name, telephone and post office address to which claimant desires notices..t° be sent, if other
/ Po .9 7o0, "_
3. Occu:ence or even[ from which the claim arises:
d. Mow and under what circumstances did damage or injury occur? Specify the particular
occurrence~ event, ac[ or omission you claim caused the injury or damage (use addi[ional
paperer necess~y). _' ~ ~ ~ ,
~. What particular aCtion b~ th~ ~it~ o~ .i}s ~mploy~es~ ¢~us~d th~ ~lIe~d dama~ or
Give a description O' the injury, properly damage or IF-, so far as is known at the time c
this clmm. If there ~. ~,'e no injuries, state "no injurms". [.- '"
Name and address of ar~y other perso¢ injured:
Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs: ,
c. Total amount claimed:
d. Basis for computation of amounts claimed~(i~c~de ~pie~of all bills, invoices, estimates
Names and addre~es of ail witness~ hospitaIs~ docLors~ etc.
d.
Any additional information 'that might be helpful in conslderin~ th~s claim:
WARNING: IT IS A CRIMINAL' OFFENSE TO FILE A FALSE CLAIM! (Penat Code Section
Insurance Code Section 556.0)
I have read lhe matters and state~nents made in the above claim and I know the same to be tEue'of m
own knowledge, except as to those matters stated to be upon information or belief as to such matters
believe the same to be true. I certify under penalty of ~er~ury that the foregoing is TRUE an
CORRECT.
Executed this / ~ d'ay of
Office of the City Clerk,
[ustin, California
CLAIM NO.
DATE FILED:
3GR:se:D:2/5/SO
T/Claim Form D:ll ~