HomeMy WebLinkAbout3. Closed Session - Claim No. 2023-17 - Marc BanksonFor City Use Onlyurh' n
CITY OF AZUSA
CLAIM FORM im APR 21 P 4: 59
(For Damages to Persons or Personal Property)
INSTRUCTIONS
against the City of Azusa for death, injury to person, or to personal property, must be filed with the City Clerk of the City of Azusa
within 6 months after which the incident or event occurred. (Government Code §911.2.) Claims tor damages to real property must be filed not
laterthan 1 ycaraftcrthcoccurrence.(GovemmentCode§911.2)
Where space is insufficient, please use additional paper, identify the additional information by the same paragraph number as the claim, and
sign each additional sheet. Submit estimates or receipts with the claim. Original completed and executed claims must be delivered or mailed to
the City Clerk, City of Azusa, 213 E. Foothill Boulevard, Azusa CA 91702. No facsimile or e-mailed claims will be accepted. The contact
number to call for additional information; (626)812-5233 or (626)812-527L
Claim
TO: CIT\’ OF AZUSA
CLAIMANT INFORMATION
Name of Claimant:
Telephone Number: ?7g
Address:
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y.3Age of Claimant;
2. Name, telephone number and mailing address to which claimant desires notices to be sent if other than above:
INFORMATION REGARDING THE INCIDENT
3. Whcn/whcrc did ihc DAMAGE or INJURY occur?
Time:
4 How and under what circumstances did DAMAGE or INJURY occur? Give full particulars; ^ --
Location;Date:
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5. What particular act or omission by the City, or its employees, caused the alleged DAMAGE
errmioyce(s) causing the DAMAGE or INJURY if Jcnuwn:
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INJURY? Give name(s) of Cityor
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6. 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,
Slate "NO INJURIES^-),- ) //
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Closed Session Item 3. CONFERENCE WITH LEGAL COUNSEL – LIABILITY
CLAIM Pursuant to California Government Code, Section 54956.95. - Claimant:
Marc Bankson, Claim No. 2023-17; Luis Villa, Claim No. 2023-22; Michael W. Song,
Claim No. 2023-25.
Agency: City of Azusa
FINANCIAL INFORMATION
$Amount claimed to date;
Estimated future costs:
Total amount claimed;
Basis for computation of amount claimed (include copies of bills, invoices, estimates, receipts, etc.).
7.
yf- *0^**? 18. Name and address of witnesses, doctors and hospitals;
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§READ CAREFULL
9. For all accident claims place on the following diagram names of streets, including North, East, South and West, and by showing house
numbers or distances to street comers.
If City vehicle was involved, designate by letter “A” location of City vehicle when you first saw it and by “B’ location of yourselt or your
vehicle when you first saw the City vehicle. Indicate location of City vehicle at the time of the accident by “A-1 ” and location of yourself
your vehicle at the time of the accident by “B-1 ”and the point of impact by “X.’'
Note: this diagram can also be used for other type of accidents that require a diagram, if this diagram does not fit the situation, attach
hereto a proper diagram signed by the claimant.
or
ACCIDENTS
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ADDITIONAL COMMENTS
10. Any additional information that might be helpful in considering this claim:
WARNINGiIT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM (PENAL CODE §72; INSURANCE CODE §556.1)
1 have read the matters and statements made in the above claim and 1 know the same to be true of my own knowledge, except as to those
matters stated upon the information or belief as to such matters I believe the same to be true. I certify under penally of perjury that the
foregoing is TRUE and CORRECT.
Signed this day oi flpfff -.20^, at
Claimant Signature