HomeMy WebLinkAbout3. Closed Session - Claim No. 2023-22 - Luis VillaMUSA CITY eiER'sT
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CLAIM I'OKM
(l iM Diuiiiuics lo I’cfsons ('r I’cisoiKil l’m]'ci'ly)
INS i’KCCTION.S
I i.iini. a;j>imsi ihc I il\ nl A/u-;.! for liiMlIi, iiijui \ In oi In |insnnal |irn|K.’rly, imisl !)c liicd willi I lie ( ily ( Icrk ol liic ( ity nl A/usa
w i'.lim (' immilis allci uliiiTi iho iiiciiinil nr ni-aiirod. (I i(i\aiiiuciil ('ndo VM 1 .A) (Taiins Ini daiiuii’c. In real prn|>cily muM lie lilcd nol
i.Uei than I rear alia llio nceiiiience. Kinvcinaiciil Tode V* I I ,.T)
\\ licic '●I'acc is insul'lK ieiil. plcasf use addilinnal pajHii, idcnliK Ihe addiliniial infni malinii liy liic same |iara;;ra|iii iiuiuIkt as Ihe cl.iiin. and
'ipn eaeh addilinnal slieel. Sulimil cslu-aali's ni icecipts \uili ilic daiin (>n)'.mal I'nmpk-led and esccutcd claims imisl lie delivered nr mailed In
llie (Tly (.'ieik. (.'U\ nl Aausa. .’1 '> I Innllull Hniili-\aiil, A/usa ('A '>171111 No (acsimile ni e-mailcd elaims will lie accepted. Ilic cnnlacl
miinl'cr In eall I'm addilinnal mini maltnr, i(>.lMS I A'nt ((i.liOS 1 I
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Cd’lL1. Name nf Claiir.anl
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rdephniie \i:mhn
2. Name, lolophnnc lumil'cr .uu! mailiiui addre.ss in which elaim.int desires imlices in lie seiil ifnther tiian aho\e:
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I.NKOK.MATION RKGAKDINC 'mi-: INCIDK.Vr
A'iien wiicrJdid /he D.AMAGI; or INJl'RT' occur?
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D.nc lime:..ocaliun:
d. i low and under whal eircumsianees did DA.M AGI; or I.NJURY occur? Gi\o full pariiciilars;
t^UCA"^ _ IW Uupne, \\<.VJlY'U lC\cl ij Z'rTr'S'iy-^ZTJ/rJ
-AS 6 /^?L’^5f<r^
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5. Whal parlicuiar ael or nmisMOU hy ihe (Tl\, or ils cin|dn>ees, caused ihe aileyed DAMAGi-, nr INK l<\.‘ (Jive iianie(s) of City
cinplovec(s) eaiisiny ihe DA.VIAGf. or INJl RT i! known:
lym'tCnofCi'Z . W^^liMr'inC'C (pf Sc-tvYlC H
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6 Give a descriplinii niThe IN.H dA . prnpciis OAMAGl or 1 OS.S, so faras^is known .u the limeof|iiis claim. If [iiere wete no IXJl. Rll-S.
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riNANCIAl. INFORMATION
SAmouiU claimed lo dale:
lAiimaied fiiiurc cosis:
I Ola! amoiinl claimed.
HaMs for cominHalioii ofanioiin.l claimed (include co[ncs ofbills, invoices, cslimalcs, receipl.s, cic.):
$
$
r t-i JqftName and address of vuinesses. ilivlors and hospiials'rj( i‘s
:l.
KKAl) CAKKFI.M.V
l-ur all jccidcnl claims place on die I'ollowiny diagram names of sirecis, including North, l-.a.sl. South and ^cM, and by showing house
numbers or distances to street corners.
If Cits vehicle was involved, designate by letter "A" location of City vehicle when you fi rst saw it and by "B location of yourself or your
vehicle when you fi rst saw the City vehicle. Indicate location of Cily vehicle at the time of the accident by "A-l’ and location of yourself
or your vehicle at the time of the aceidciil by “U-r' 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 docs not fi t the situation, attach
hereto a proper diagram signed by the claimant.
ACCIDENTS
JSIDE\VAI,K
CURE
CURB
Z
SIDIAVAI K
'1AUDI I lON.U, COMMENTS
10 Any additional inl'oinijiion that might be helpful in a'livdering this claim' Crl'l
f\cWvii c’l>T.T {\]C \o
WAUMNUii 1 IS A ( RI.MINAI. OR FNSK 10 HI K \ FALSE ( I MM (I'F.N M I ()l)F. Ij?’; INSl U \NCF CODE |555fi.l)
r>O'
I li.ive read the malieis and statements made m the above claim and 1 know the same to be true of my own knowledge, cseepi as to those
matters Mated upon the information oi helici as to such matters I believe the same to he true I certify under jK-nalty of perjury that the
Idtegoing IS 1 Rl 1- .ind CORUl Cl .
zy ,:o23pnday ofSigned this
'laimant Sign,ilurc