HomeMy WebLinkAbout3. Closed Session - ClaimNo. 2023-25 - Michael W. SongI Ml ( ih l -'M- 0:,ls ^
n.AZiU5A CITY CLERK
20Z3 JUN 13 A <1: ! I
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n 1 Ol' A/USA
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n.iini, .u;.nnsl ihc ('ils oC A/ii.-'.i liu ilc.ilh, iiijiiiy lo iiitmim, or lo pcrsim.il |>io|>ci lv,
vMihin (. monilis ,Ula wlnoh ihoinadcnt oi ovcnl oa:unr.| .((.iovomiiKm (.'ink-I ri.ntii'. loi il.im.-rrMo m mI I..- hi. .I imi
l.iici ihar, 1 .ilk’r ilic iH'Cuni‘noi.v (Clo\L‘nimcnl (.’oilo I
Where siucc is msunK-icnl. ptc.isc use .uklitiomil paper, iilciili ly llie addilmiui mConnalion hy llie ●●.mu- p.ii.U'.Mpii iimiiba ,r.
sii-n each addilional shcci. Siihmii esiimales or ieecii)ls willi die claim. Original complcieil ami c\cciilnl claims must be .Iclivnc.l m mmlc.l m
ihc C'il\ Clerk. Cilv ol‘A/iis:i. 1;. 1-oolhill lioiilcvard. .A/.ii.sa CA ‘M701 No l;iesimi!c or e maile.l claims will be aa:c))lc:.i. Ihc coiiiaci
mio.1 be lilc.l oilh ihe ''c^ led. ol il.e ' iiv ol A/iis.i
liumher lo call for adililional inlormation: (h2<))S I or (h.1b)S 12-.‘^27 i .
10: Cl l‘V OF AX.I S.V
CLAIMANT INKOUMATION
. Name orClaimani: ''A loViC'CT -
Atkiicss:e .a,
.iA-NC I
^A ●
rdcpiionc Niimher; \’
Aa-.. cj A).’,c ol'Claimaiu:
which claimaiil (lesires luiliees to he sail i l'olhci llian above2. Name, (deplume luimher and mailing aikiress U>
INM'■ OiiM A1M()j^IT_;/U< 1MNO T11F II> K
3. When.'svhcrc did die D.'WIAGI'. or INJLIO oeeui!
Dale:^ -IS-CL. I ^^3 Time:I hC-LCkvYhT/l.ocadoii; fe csTK:P--.-c.v>^-
diti UAMAGiv or INJURY occiirV Give (‘nil [rarlieularHow and under s^■il:u cireumslances4.
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5. Whal part,CL.br ac. or oiiriasion by Ihc City, or lb employee*, earned Ihe allcpcd DAMAOI, or Ihrtl 'KVV Ciivc aa,nc(s, of ( ily
employee(s) causing llie DAM AG 1: or INJURY i l known:
r-
■^FV^xrO A A' COCriGj-iSbi.
is known al the lime ol'lhis claim. I l'tlicre were no INJI .HIb.S,
description oClhc IN.H-RY. property DAMAGh. or l .OSS. so lar as is --
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3>Av'd'-T'N'U^'^
O INJl RII--S-
●’jJ3. fA-^t irF-A'u-
Give a.
stale -N 'I'..
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he.
FINANCIAL INFORMATION
S7. Amoum claimed to date:
F.slimalcd future costs:
Total amount claimed:
Basis for computation of amount claimed (ineJude copies of hills, invoices, estimates, receipts, etc.).
1 ^ C:>>T ^
S
S
Name and address of witnesses, doctors and hospitals:
READ CAREFULLY
For all accident claims place on the following diagram names of streets, including North, East. South and West, and hy showing house
numbers or distances to street comers. .. r
If City vehicle \\’as involved, designate by letter "A" location of City vehicle when you first saw it and by -13" location Oi you.--scH 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
or your vehicle at the time of the accident by “B-l" 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 lit the situation, attach
hereto a proper diagram signed by the claimant.
9.
ACCIDENTS
SIDEWALK
CURB
CURB
Z PARKWAY
SIDEWALK
ADDITIONAL COMMENTS
10. Any additional information that might be helpful in considering this claim<2^j^:;:;^
WAR.MNG:IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM (FENAL CODE §72; INSURANCE CODE §556.1)
+
1 have read the matters and statements made in the above claim and I know the same to be true of my owti knowledge, except as to those
matters slated upon the information or belief as to such matters 1 believe the same to be true. I certify under penalty of perjury that the
foregoing is TRUE and CORRECT,
day of ^5 I Q/, 20.Signed this , at
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