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Home My WebLink AboutMINUTES - 11091993 - 1.12 • � � ;` OCT 1 51993 y CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA COUNTY COUNSEL Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT NOVEMBER 9, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $605 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: CARSON, James V. and Barbara ATTORNEY: Date received October 13, 1993 (via Public Works ADDRESS: 13580 Marsh Creek Road BY DELIVERY TO CLERK ON Clayton, CA 94517 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 15, 1993 H�IIL BATCHELOR, Clerk DATED: lr: Deputy 11. FROM:. County Counsel TO: Clerk of the Board of Supervisors ( Y') This claim complies substantially with Sections 910 and 910.2. ( ) This claim- FAILS'to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: e Dated: BY: Deputy County Counsel v 11I. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (v4 This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:`4&1,i,,,,,,_O.e, 1993PHIL BATCHELOR, Clerk. By �J) �g ) Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California. postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated-�2D-�",_ ( hi kgQ,:�,_ BY: PHIL BATCHELOR by , ��a�Q�� Deputy Clerk CC: County Counsel County Administrator 4 Claim 'to: BOARD OF SUPERVISORS OF ca.-mm COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action.. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp Jcrr��e U, RECEIVED Against the County of Contra Costa ) OCT 1 3 lM or ) - CLERK BOARD OF SUPERVISORS District) �{ CONTRA COSTA CO. Fill in name ) NAND DELIVERED The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 6 6 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) --------------------- i- — ------�L-�— u--- -------------------------------- 2. Where did the damage or injury occur? (Include city and county) /3��o AI-0-12,541C��ee� ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) �9 ,4,,,, pt(e 73 /-f 7 e XvKs .0tce_ 'T ,,t4e_s> /L, 4ex_c_0 ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? (over) r 5.,_ What are the names of county or distf-ict officers, servants or employees causing the damage or injury? 2Al Q ------------- ---------------------------------------------------------------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 'i.. ----- --- J s s_a _CJ —P==------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) � �as1 or ��7(-X,6, 6� `- - 4'ems' ) ?-0 oPJ L.mssl"'300 ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 3 Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney Claimant's Signature Address 7 Telephone No. Telephone No. # # # # # # # # # # # # # # # # # # NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by,a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. cCT 151993 CLAIM t� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA', COui ?Yw�li;SiL Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT NOVEMBER 9, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $500,000-00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: DILLMAN, Patrick A. ATTORNEY:, Date received ADDRESS: 901 Court Street BY DELIVERY TO CLERK ON October 12, 1993 Martinez, CA 94553 BY MAIL POSTMARKED: Via transmittal I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 15, 1993 PpHHIL BATCHELOR, Cler DATED: B : Deputy I1. FROM: County Counsel TO: Clerk of the Board of sors ( P� This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: /gp� BY:. Deputy County Counsel I1I. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (v4 This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:` � ,,4,� 9Jg9_PHIL BATCHELOR, Clerk, By � 1k.4 . 00,-- ) Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated ^� 1 D. f�19 BY: PHIL BATCHELOR byN�l_('A-4,4 Deputy Clerk CC: County Counsel County Administrator J - - - -- - - -�.-c ._ - - - OCT I-2 ----------- - � � - 1 �J - ---- - - CLERK BOARD OF SUPERVISORS CONTRA COSTA CO--.47 --- - r 41 - - ------- --- -- T Claim -to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa ) OCT 12 1993 r. e CLERK BOARD CONTRA®ISO OS A CO. (Fill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ y 60 , 0e) 0 , O P and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) _s e e eo 4. What particular act or omission on the part of county or `-,district officers, servants or employees caused the injury or damage? s Q TT�C�P,Q (over) 4 5. "What are the names of county or"district officers, servants or employees causing ' the damage or injury? 1 ' A 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates. for auto damage. --------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) a 0 O ,c .1�-Z e_✓�_ 8. Names and addresses of witnesses, doctors and hospitals. S P C A 7-7,4 C y e"i O�s.�� e /P S , ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney .� &474?;cA ,4; Claimant's Signature 7'",fV e Z (2 (Address) Telephone No. 4/0 6LC7,,V e- Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district. board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. MITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA lJ !� (Enter above t o rull name o the plaintiff in this action.) -v- No C Complaint -Under the CN71 Rights Act, 42 USC S 1983 e=rr 17ad 14 gf rater above the full name o the defendant or defendants in this action.) I. Previous Lawsuits A. Have you begun other lawsuits in ,state or federal court dealing with the same facts involved in this action or otherwise relating to your imprisonment? Yes ( ) No W B. If your answer to A is yes, describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper, using same outline.) I. Parties to this previous lawsuit Plaintiffs Defendants 2. Court (if federal court, name the district; if state court, name the county) 3. Docket Number 4. Name of judge to whom case was assigned S. Disposition (form example: Was the case dismissed? Was it appealed? It is still pending?) -1- 6. Approximate date of, filing lawsuit 7. Approximate date of disposition II. Place of Prer,ent Con inement 00A.,Y � 6;,$-7,0 i4 A. Is there a prisoner rievance procedure in t _.institution? Yes � sNo ( ) B. Did you present the facts relating to your complaint in the state prisoner grievance procedure Yes qQ No ( ) C. If your answer is YES, 1 . What steps did you take? Q.SVt 7'S 2. What was the result? .,Q . D. If your answer is NO, explain why not E. If there is no prison grievance procedure in the institution, did you complain to prison authorities? Yes No ( ) F. If your answer is YES, 1 , What steps did you take? 41 2. ..What was the result? III. Parties (In item A below, place your name in the first blank and place your present address in the second blank. Do the same for additional plaintiffs. if any.) A. Name of Plaintiff Address Q j ,f-- (In item B below, place the full name of the defendant in the first blank, his official position in the second blank, and his place of employment in the third blank. Use item C for the names, positions and places of employment of any additional defendants.) B. Defendant e /C1GL S D°10Q/i is employed as jD��cG y 1 1? ,�!�w d'� at C.G�I-Ay Co 5.7.E L'Gan-7 -2- C. Additional Defendants �° i P ti ,v T i IV. Statement of Claim (State here as briefly as possible the facts of your case. Describe how each defendant is involved. Include also the names of other persons involved, dates. and places. Do not Rive any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate paragraph. Use as much space as you need. Attach extra sheet if necessary.) /l 4 ST O g e O ti% o • i a ee e? 4", Mn TS-IC4 OP Z2 CL G �. o x u s e © j` T 60 f'" -- T 1 G F N G " a' C - :A ! Z . rP s4 Ef-t"z4:1V 9/41;1/t Q T" G/ r i / . V. Relief (State briefIX exactly what you want the court to do for you. make no legal arguments. Cite no Fases or statutes.) �s . Q S W,In Q Ar , 0 h/ �U '►� evsr ri Signed this day of C)C7-a,d 04 19�. r gnature o aint I declare under .,penalty of perjury that the foregoing is true and correct. Vr/"— Date (Signature of P a nti -3- j UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA FOMMX PAUPERIS' AFFIDAVIT • I hereby apply for leave to proceed without prepayment of fees or costs -or security therefor. In support of my application, I state under penalty of perjury that the following facts are true: (l) I" am the plaintiff, and *T. believe I am entitled to redress, (2) I ani unable to pay the costs of said action or.-give 'security, because: •Ar )O_ /Y•q U G id ' 1-31041/ 14 (3) The nature of this action is: . r • ate ignature of Petitioner NDC CSA-13 1-81- pa A I 1A )O uta S -J-'jG f�wi .rV 'l ,�' ._L°.� ��. CJ 7-//.C. i r ' i _000OwRa -.7. , too c OZ l , i , O't 37y 13 _ i rev Ag r. -- - - � .-. __ _lel . 7 f�`�� -- "' ._ • _ 1 : L' /P Ar yp oor 10/ ------------ -- fi. M'_�� j'r �._ 6�'� I fay !i ,� �'�fa•°pv°' .f:.�- ,! i� F'-` _.� � Grp-� 0�� Gfr�-�'_ • wow Ale- _ 44-�,,C e S 7, 1�45 fes_ kv ',4 L ' /�' 4�-/ CERTIFICATE OF SERVICE Case Name: /Vt •P"Oy v. �G.4•rll.Q(_ocS r-�9 ( a�wr S� ��il Case No. : IMPORTANT: You must send a copy of ALL documents filed with the court and any attachments to counsel for ALL parties in this case. You must also file a certificate of service with this court telling us that you have done so. You may use this certificate of service as a master copy, and fill in the title of the document you are filing. Please list below the names and addresses of the parties who were sent a copy of your document and the dates on which they were served. Be sure to sign the statement below. You must attach a copy of the certificate of service to each of the copies and the copy you file with the court. I certify that a copy of the pLJ43L%C -e�/7"/ T (Name of document you are Y y filing (i.e. , opening brief, motion, etc. ) and any attachments was served, either in person or by mail, on the persons listed below. Signature Notary NOT required Name Address Date Served Co�rrq��o S714&441.7y �ySS3 ps7�► Gyp X30 9 R,0 D'c .SONO?v,Sc,�s �� 7 J ti¢ Z, JLQR71/PRiL owL , yS'O6 4A7el9vP� J � O y,S9r�Cil�C'cr 0,04 e �,9o�Al J S10" 'log 4te;SCaJ C.9. �Wj 9 3939 INNIk PROOF OF. SERVICE 2 I hereby declare that I am over the age of 18 years of age, a resident 3 in the State of California and a party/nor a party to the within cause of (mark one out) 4 action. That on this date I *did cause a true and correct copy of the 5 to be served on the parties to the 6 action by: (check appropriate boxes) 7 tW- depositing same in the U.S. Mail "with. first class postage prepaid and addressed as follows below; 8 /_7 delivering same in person. to the address as follows and placing into 9 the control of the below listed party or their representative; 10 /` ' w �` b�7'//��4 &TIV lelCOURT 12 TIN , - CA. ' S'%�PrP/ �'itSL'� CA. 13 14 ,� WINE smia 17 00i A,'LO STr, VERIFICATION 18 I have -read the above statements and do declare upon penalty of 19 perjury that these statements are true and correct as based .upon my 20 information and belief. Executed this day of �'�C.T Q6 e 21 19 C' at / T/, , California pursuant to provisions- of 22 Code of Civil Procedure, Sections 446 and 2015.5. . 23 24 25 DECLARANT 26 27 28 v , Zi XYR ,,; { '�ct t d .✓ // 'Y I tr r � ✓ s t t Y - �.. Y' ! X I Ste". t Ft; f R v r 1 � k CO Co y y CD CD'. 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I I t;:�. .i I I.$ ,, lo:'�!��:'�"'�" rn / "� a� v y � ': �k ., I .- � - ,� � �'�:�0 :�',�1 04 ;..0 v }: 11 D" ,f ` f i .� `fix s r; �� r 8 t. , X!11 " N %. � a� x� ;! t r .Itt. �.' ffi. «� � . 1 �l t::. ;:.1, 11 ; a` ..i.. .. 1. 1. :: ,-1 k.`! ',. � ' �`^ '; �„ .�� Y. �.. . 5uperior Court JOHN C. MINNEY 5 as to of (9a1if=in i, f .'• JUDGE COUNTY OF CONTRA COSTA DEPARTMENT 12 A.F. BRAY COURTS BUILDING {,� t '.. ''.. 415-646-4012 ,� 1020 WARD STREET >.'fe"u'r MARTINEZ, CALIFORNIA 94558 May 26, 1993 Patrick A. Dillman Contra Costa County Jail 1010 Ward Street Martinez, CA 94553 Re: Patrick Dillman Superior Court Case No. 931613-4 Dear Mr. Dillman: In response to your letter of May 18, 1993 and attachments: 1 . I have advised the District Attorney (Mrs. Mary Ann O'Malley) , of your Federal Court Rights lawsuit. They will advise me of any response. 2. The balance of your requests should be addressed to your attorney or the jail administrative staff. ;6n rely, C. inney of the S erior Court JCM: jo cc : Mary Ann O'Malley, Deputy District Attorney Stuart Willis, Attorney at Law File 7- 17 C, 7 1,9 IL IT 77' )vc 7 0 a 1*911le Ar I" 4r e dy z2 S' av L, C L i-w 7- ie #Vlo zo, C)°' N O 0- Z + O.?.N Ql N 0D Z ma�N pt m�� fi N q .o wato 6? � =60"�p G � n '� ? ;'::I to O SSG N. �. C10 3 G� 6 m m m 7 a 7 m y%"C N ?y p �•� as-3 O O n 0 m%l ?c(O� to t�? Z+ 0 .4 D'0 caarp 40 pCD N�j o?� 3a^� m��r 3m�� P �m Z-4 � m �7 Gia OQG OC000 ?�m �^a Q D4 Q.VD. ?.?pO?^m-, � m`na-,cam wcNr 'wro snf aw o 3`wfm° N• m N N O dr,- %•c0 0 4+4 t^..t- ?�O a m CD 0 O N - D 0 t' mm0G 0 o vow• �� 0044 0°' NC)m -,r 3a C) c� p, CO -n V St7 G,- 7 7 m o4m m 0 t9 a Or. C- ¢.r. m a A l0 O t9 A O cp m -n CD to l trf 0:4 ?m0 16 —tot' >O Nm0 pp00 u+3p.-D u't 0 n r `Z 0 �O o� ? C, G•O ? O O ..} a aOp�� d w:•� < ? 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'Cti .� � -tit �• O }•� -(D O :10CD 0 m {' fl. ` Z • CD # ' "'� `• m co m � In S. r) x _> �, �: -. ;•�- �� . � .. � . �= �, ��'" ��> ,,.y.�, �` .. �-., �- S�/r � � �� `�`� � , � �` °� .�` w,,. V \ .� � y ._ " � � �� ._� � _.� �, -�,°, �� -,� �, �, ��` �._ .� _, ,��• �. , =, '�'"�`��a.,.., ,_.�, ,.� � �, ��,_. "� �; T� - ,J ,ty...., �`��- � �_.-� �'�� .� .,.� �,,..� r CLAIM " � OCT 5 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA i C01INT'/COUNSEL Claim Against the County, or District governed by) BOARD [AGT1IONy�IF the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT NOV EMB E R 9, 19 931 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $500,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: EVONC, Mi chan R. ATTORNEY: Date received ADDRESS: 2600 Jones Road. Condo 1 BY DELIVERY TO CLERK ON October 13, 1993 Walnut Creek, CA 94596 BY MAIL POSTMARKED: October 12, 1993 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 15, 1993 HHIL BATCHELOR, Cler DATED: �1': Deputy II. FR OM County Counsel TO: Clerk of the Board of Su sors ( claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ) . (rt.� J�, 993 BY: 4, e, AL, Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( V�This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:JJymqf,g Q)qq.3_PHIL BATCHELOR, Clerk. By 44.4.4� Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately, *For additional warnina See reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez. California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. D Dated:X D,�kA4 I tp J�S BY: PHIL BATCHELOR by 1 . Deputy Clerk CC: County Counsel County Administrator _ RECEIVED - OCT 13:r:] - -CONTRA QDS17� SOAR D . aA7 SUP�:RVI-�ORS CIFRK BOARD OF SUPERVISORS _ ou�lT\(' - lb M It41S-i RA tlOtA NIRA COSTA CO. CSA-- PA STREET MEDICAL MAt__FRAC17CE Dc:Ni ,L wE-b\GAL EnTvt�ai. - - DtS�RyczC�a a"7 k- s ,AL PRo��ri� - - - DEAR ADM N-ISTZA U- R . - - -- - -- ----A-MM- EV'� _ iS \-/C t,oR _ IDR CLAV1 _ FORM AMD- - - CCK OF _1H � _SUPCRta C3�-S TI 7-kU�1G tN FAP,-T _ _- FOR__ PROt1 5CTIaq / G--_A DIST DITIC - =(\CtLIT`1_ - - LU-R _ TO- FROV)E N1 D1 CAL TRENTME T AND -. -- - CTH EV FkEC�U 1 RSD MAD - _ COMPUAtACE _-- W1714 iH LAW, cFS A\D Mt�1�S t�ATt�tE ------- ------ -- - __- - ��5��L _TO - - _ DetV C A-� WT ACT- hPaN H IS -MFT - C1AI M -- 7- ANM U s i 1 N-G- YC)OF, 'DAN IAL -L -moi CER OR N7R -1 NA N Z MAY_ F= tom.- A_ CdPy SMA TH - - - 1�1Y _ S-A-T\�T-E F)9))E;:?,AL SUiT _ - N1y cc�4ACERN FOR _t Rd�"1PT ALTt�t� St<RR�uNDS - MV-- PERSbNAL \41EAC M r W ELFART-- At\1D SAT=s/ -- --- --- -M 1-M t CH VS -AN-D kAAS - J13 TNR_EAT N 6V - - - --LAC- _OV 1t IN FF Ef BZ Ct 7-0 MV -URREtAT ANS - -- - MEDICAL _ _Tt4 is FAO LIV _RIEF l 1 S A L _ QR - Mtn UT-`1 CC 4STWT PA 4 N_ ac) 0 C"'EST MOD t--AEO1- - -- - -- - -- -Col\m KC51SS SA IELU NkG . SL T A til ECK f_S,"C k-1LD-ER - - - - - L LF T. -S\�)C-7- AND FAt t_uR E - FR aV t DE "TtA E - . -- - P4�OPER - 'utE% HAS -1��,EN MOST- �N6EA1�A��i✓ _ At l) L«_E - APP RoxtMATe-V --VWo Y .ARS AQo _1 A LMoST - -- S 3FT-ER A L-11=-E -t1-4 RE)ITE-�ING M C-T-).t CA L CR k S 1 ,S _ W\S..t�us- OA �� fkos, Pn-NL. QECAvSE -TH E - - ---- -- --M'E"Dt.CA-L- -�tJ FIT=--(l,-WFSES - AT TcVE-TttME�_NI DL- --- - — -- LLE--A.L__M1=9tCA_L _-- ----- - -- ------- ---F'ERMrIi 4tAi -T-C)- OCCUR . AGAIt4p - M-JEDkCA.L -SAF=IF- --HAS F,EFOSZ -TZ-') SEE ME - - ES P3N D EP vel-rEEVL)/ -V"/T ` fm CN TIA 1E7 M ED i CA L.- _ -UST ! IgcFl __ AUGUST l[-1 lS - lS _-SERkc)oS- - - - ASD 1 F. A17- WA S�l'T Y -V"E GRP.CCE C-oDj T- -. _ -- PRCoSASLy Nc�),spk77 - b�.�EC�cAS RCQusV-1Ncz, i N\S l3c�AtR� - Cc�RRcT - - - -UE IST 1 CTt_nhl - - - - - -- Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp ICH VAC. � RECEIVED Against the County of Contra Costa ) OCT 13 M or ) District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ S'or1�p, OZ�. and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) -----------Z=_T'I_F_MBZ__ .._L9 ---- 2. Where did the damage or injury occur? (Include city and county) --- -8-�1.�. Z C2�13t�1Tt/ 1L M�R.lt----7� CA_--553------- ---- ------ ---------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) ----------- L-- Fb ------------------------------------------------- 4. What pa.rticul�r act or .omission on the part of county or district officers, servants or employees caused the injury or damage? (over) 1 ' 5. What are the names of county or district officers, servants or employees causing the damage or injury? -------------------------------------- ------- --------- 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 0 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses, doctors and hospitals. C-7CC)RDS �E�Lc� It�l MA URSY S� Lt ST— ------------------��=- L�1T`l-=--------�^�-------- =- ------- ------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney L Yl Claimant's ignature OaLL Address V, Q I Telephone No. Telephone No. * * * * N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district. board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment .in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. at--_SUP - __ __- -- ------ 7. GROUNDS FOR RELIEF Ground 1: State briefly the ground on which you base your claim for relief.(For example, *%he trial court imposed an illegal enhance. ment") If you have additional grounds for relief, use a separate page for each ground. Pages 4 and S are designed so you can state grounds 2 and,I. For additional grounds,make copies of page S and number the additional grounds in order. FAILURE in PROVILE A MT)1 ZAl PRESCRIRFD DtE't FAI 111RE -i-D PROU)'P A LW-E SE: D. =L CWA F'At l t ig h TQ MCSN t i oR LEvFL(s CSF SoldliM � FAT., CHOL•E,2R R L. PURSWAN T TCS ME ICAI_IY ACCEP-JABLt AND MLDICAU=y a. Supporting facts: (Tell your story briefly without citing csses or law. If you arc challenging the legality of your conviction, brief- ly describe the facts upon which your conviction is based. If necessary. attach additional pages. CAUTION: You must state facts, not conclusions. For example, if you are claiming incompetence of counsel you must state facts specifically setting forth what your attorney did or failed to do and how that affected your trial. Failure to allege sufficient facts will result in the denial of your petition. (See In re Swuin (1949) 34 Cal.2d 300, 304.) A rule of thumb to follow is: who did exactly whar to violate your rights at what three (Aen) or place (Acre). If available, attach declarations supporting your claim.) �INCIE M\ A€MWAL AI G-AIST I (at 1993 A T MART AEZ C,nut\1'TY SAILTHE "TAIL TODD SF(��1C� MAt� AGmac, `C"C1 �AM C)R M\/ M E-7-D 1 C AL D1 ET ()F LD w .SA L-F/Eo n m M L FAT /Ln«I CL~E'S-a7: Mn_ �=tSA H tN PIRA, A1,lD R F i tC.tr)� s D -T vlwcI4 HAS, i ELPABMSIED MY !- F-A ►TF4 / RASW. WELEABE A U t) \t\l i41 4KA4 \S L P E .TI R c A-T Elul t N C,- A U"D C.R E0 L &,I D -13W LS A 1 PUILL"M 1 AT AS D[-D LI F- D B\/ T I-4 E CnWaM-Tl Mots . = HAVE COMPLAtNM AW) E�tLEi> S E V PP A l C—tR l h VA N C E=S \A 1 C H MEED 1 C A.L_ STIFF- b. TIF•Fb. Supporting cases: (Briefly discuss or list by name and citation the cases which you think are factually close to yours as an example of the error you believe occurred in your case. If necessary, attach an extra page.) T t-n E \-5 IVI 11.11 M t t M URt t STAN 1DAFX. S Pte- lA L C`C�nt= S :L-1c)\s-- 2, PE-INAL Cbr-) SUCTI '�,W PL-Ai CM)E SECTT G n-SC) AOC-512b Page 3 --C®NTIN U AM c) A _ G9O0ND. _- M A NDA.T ED LEVELS FA- IL.UR,E TO POST MPAO IN AD\/ANCE� _- .-- _t'AlLURE TO HONOR REUGG C)US D1ET R�qutR�MC �S _ FAt LURE TC) REAL, -TNS LABEL CN UTR M oN (t E� SALT P ESTRI Cii6N LcV EL1 LOW SaD1 LM RCSTR1 CT\CtA _ - LEvE� C KFZLOG CoF A )=LAYS 9/4 C)z = Z20 NSG-, SC)WO l - 'KELLL CSS S MA\K E S l�A_% oz (po mc, SQm 1 v M - _FHC ACCEPTABLE LEVO L F-OFZ -SOD\uM �t�TAKE_ PPR LOW LC-VC-LS FCR DA1L`/ . C_Ot�SUMRi10N S"oU1_D BE- . C3CLC)W -70(:� M Gt _M _RESTRICTEfl _D\E Lt-1 1=LS l-\C.RF EXCc E -3,QW M G-. . \Aj)A 1 CIA \S DANS ®1SS f=OR H tG-1{ 13LOGD 1�AT1 \T SEE N 1�'ITS - R Cq UESS/R'F_SPO tASES TI Tt-E VT _ . - _ WAA-0 . -t1 AV E- -Z-- BEU EVE ATTEM T-ED TO 19TERVEtVE (NURSC` S )_ _BUT WERE UM 1TED -8ECAUSE THEY WC-FE ONLV PER M- ED -M COIR WARD T H IE- _ _ M ED i cA OCD E RS MANY Ti M E S t.NF-CSR M ED Tki lS o� - -- - _ iS JA1L/ NC3 _A HC�sP 1TA\-, OR HOTEL, FIAT -WE- SP EC_AA1_ D 1 E-VE 'S HAD TO EAT W N AT wJ�S - - - 1 i= -M ERE WAS AN AT79APTA TIA E �i t - WAS \A- IT --E F�EC-AFAD —M IT - -RE-C-0 LAR ITy, N EV ER C-HAN G t N G i t�C0 �IuTR.t T1ous - -- - 'FA VL.ED 7C� MEt_T MtN 1M UM STAtMAe)DS. C DtETARV - - _ - NkOT REV tEW EDt 1OR APPRDVED BY Ll CCzgS, _ - -_-- _ - - - _ - - DkL= t0ANl- AMER.tCAN DVETARy ASSoaA-VloN -- - - - DUE 7-0 f_AG-C/_ OBE-s\T,/ A�\1D CE1ERA�- - VA EA LTH C)F -FR t S P C`rCTX O N CF3 I T !-i Ml E RE F E k-TELY -- - R EQ u ES%"ED_ A M EETI H C- (-niROUC.H TTA E VARI ouS NURSE')-W t-T1-t THE D\ET CtAV� i AK .D 1F RL.FUSEL AFPROVED MF- UE AND -A. - -- - - U-ST _ OF. - FOOD 0-1SMS NVA 1 LA8LC. I N 74 IS . - - - tNST1TUTFIIION - I -I-RS_T 1 WAS U CD _T O 0 W 4 N 1 NFOR M GCS -Tl4AT- _ T-H C R_C WAS _A - -DI ET CI Atmel .09 S i 7- -1 TNN--k N1y - _ - fl1E T MET ThE ML)1CAL \1ZEC�UtRE ENTS® IT . WAS LA�T ER ACKk wW LCDG'E WAS �)\S TUKnc)t� OF.T-IE Ft&ACT/ T KAT 11.0 IS C�N ST At=F, THAI 7TH-E-RE US NO APPROgE.D lul CN Iu FOR MED\CAL RE S 1-' 1 CTE) D I ETS/ 71 AT" - _ 7=ooD SCRV i CE PSC EL/ W)IR FoODs�-7RV I CE KNOvJLED,-C MANAC--ER PCSS_E-SS AUY SPECIAL SKILLS REQUIRED _ - CSR V ITA,L FCR -TNIE PREPARA70NI PLANN\qG _ AAD 1MPLEML- jTAT10N OF- MACSE MEDICAL DIETS -.IF-:A\LUPE - AI\kD REFUSAL OF 7-WE PEgU\RE=D- - - __ -PROPER- 1)\T � 4AS FUR--1ER 1MPACiLD - \�y NEALT-1 AND WELFARE , T _AM k OC)W -- -EXPER_I ENCJ N C_ C-EXERAL_ T=ATI GUIE� \\I I C-RAtAE- _ 1=I CADACI-IES �R EZ�U ChiM l R E-PS i M Ems\T- E:VALUATIQ - - _ W)NE -GWEN -- DA\ LY COSLSUM P T IoN_ 3--� --n-ME-,S C)�- T/ENOL_/ "�T-RESS/ AG 1 1T'Ti ON /S l-t ORT- TEM PER - Wl4ICN._ __1S CAU51NG- A NE;G'ATtVE -I-M A_CT -- M\/ _ EAM.I Ly C.CNtySTANT �--1_A\R U.PSX - MY VJ l FE - _-A.N D__z _ NEVER ARGUE AS WE ARE t� owe - -- --- ----- - - -T-�iS_ HAS ALSO AFFECTED MY CASE A"D . TNS FACT i AAT MY_ CUkRF, l- DIET -0 CGS RConi-PLS W 1TlA TH AT T. D I CT oRU FRED SY- THE M EE 1 CA L STA F t<. 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TIFfl �(Zc cmc ct D 2�SSutG SAL-AD --- DQE- PLAcE NM.ATE. 1lEAOAA AT BECA\ISE -_ i ,_ F/Mus _TO_ MEET STAN'DAVrkD SET Cay t�lA"R-O�,\AL . ACAD.ENY C)F- SC'iENCES- - FCR \t�STZTU�T�N V_I OLA7-E_ -TTX-.E 15 9E PET T" C�C�S M EA-C�S - - - - R CCS U.i R EWENTS - 44FAkWRS -z -:TO 'Cc MFILY W ffkA C_140,L`CS`rRN_ REQ\3tR'E- - - M ENTS .- - - VALUE � use z� coc�PLy W TTIA FHys\CkAN d�DE_R. INMATE REQO\RED _T� P\34 DISCARtJ INAPP-R.(OP\ATS SDS— ND Rt�LAC�tC-..NT OCA SU��T1TuTES . UJv�} Sc�jy�0M' SKLTWAF FOR, ,. "ORMA� r` 0z �/!s C z. K S Fsr�aapa:l starad6read 1 C3 M ®,�,.� Exchan riarlatlon based on'Ewmanpe alcan Pw tial and 0 U Asso i Inc The American osoCWJwL NUTRITION INFORMATION SERVING SIZE: %02.(21 g,'Y,CUP) PERCENT OF U.B.ROA SERVINGS PER PACKAGE: i PROTEIN......2 CALCIUM...:..0 CALORIES......................So VITAMIN A...10 IRON........:6 PROTEIN CARBOHYDRATE, g..............18 VITAMIN C...15 VITAMIN 0....9 FAT,TOTAL. .,....... 0 THIAMIN.....16 VITAMIN Be•..16 ��9 p' RIBOFLAVIN.. 16 FOLIC ACID...IF g............0 NIACIN....... 16 SATURATED. g..............0 CHOLESTEROL,mg................0 SODIUM, mg.. ..............220 POTASSIUM, mg... .. 2S INGREDIENTS: CORN, SUGAR, SALT, MALT FLAVORING, CORN SYRV NIACINAMIDE, SODIUM ASCORBATE (C), ASCORBIC ACID (C), IRO► PYRIDOXINE HYDROCHLORIDE (Be), RIBOFLAVIN (B.), VITAMIN f PALMITATE,THIAMIN HYDROCHLORIDE (Bj), FOLIC ACID, AV-* VITAMIN D. KELLOGG COMPANY • BATTLE CREEK,M{ .W- 0 1992 BY KELLOGG COMPANY®KELIAW P'(c*1417 ve m �1 Exohanpe:lll2Starch/Sread — J N� �� Exchange piculation based on'Exchanpe �:� Ust for Meal Planning,®1989,Ameripn P G f i �aC / . D(abetes cc On.Inc.,The American >� Dietetic Association. Ground 3: (if applicable): ` ZT c= rRip- PR p,k M REFUSAL C - i iL b1�T - A1LllR "�o R LAC l��s" �y 2 Dt � APPUMA"'e a. Supporting facts: V-A� _l R>ri 'TC� MO t lZ). R/OR pl S P)UkSE MENCMIuq AS OFDELLD.3 t��Fc�a APC�Lt \ (I - , b. Supporting cases: roc-s`in PW - --- -ME-ATM Eiy i - TAA LV RIE -T�) M C)q Vm P M EDtCA\- -- - - - - �\ ET - AW,) DF-STRIA CT1 c�tA OF M E�VCAL - - - Appu,A.t`Sc� - �c�ivE �Aiti1 ANS S��FER1 Gr - - c tUACE- ---My _N- CAF CC-RA-ncA AUG\Ss7 t�,� \qq3/ -_ W A T TM PT'ED_ k-3 - \4M U� M,/ M.E't CAL _NODS _ AD.D RFSS Eb_ -k-WA RESFaAtS\V_E./ .F ROFESS1NS ABLE. .MANN IE--P, - _ CCN"ZA --CAWS_ ANkb SYSP,To1�ts . _ C-kAESQ pA\tJS. - (A) ATCRC<. _ 66) t4 t G NA -BLOdD PSC-SSS 41F - CC) zcv EL. - - - - - -- .AND_ _ AECK___C POSSIBLE' _ 4ERWA DISC. oR -MMO.0 -LO-W. -BA CK, - - _ -- -- UNA DD-RCSSE� SYMPTC)NS -- GIE NIER.At_ t=/�TIGUE - - C-XCESSwE _1A 0A.DACH4ES(MIGRAN.C)- CONT(.gOUS. -- - - --FA1 til U W. _SACK PAI RS - - Lo.WANcF-/ARcuMot AT1VE- FA7C-,uE - _ -.- 12 Ob til oc) 1A _--T EXP R ESS TG- BOOK i t4 . T-4 A T T W A S MEDICAL_ - CLMSt%1ED_ - INMATE 114AT .= RE�LtRIED _ _ CERTAVN._ M.E DlCA-MIAs -MAT WERE CcNSFic^TIIF-D SY _- A SQL--Ru \4 HO .Toss MEDtCATION GARBAGE 1=_SEP-iaCLE- A"b., \t `F'OR-MI=D - ME- TKAT -1: WCOLb :tat - _ SE�tA _ Bv- _A _M_EvtCAL 11ATAKE W ORKC-F�, - - - - - -- L -_ ?C_PLA k to-L D ....M\-1 - t\4 D POR M`/ . 0 EAR-T/ \4 t C-. A �t�D CATs C _ l t� CUD I N C PaSSESSt CA C�F M y__ N4 TRO E I_Y c�-R -.--D1c". 7-�A E - (!�FFtc.ER -vAARC-A-kl to ME W " - -- M IED-\CATtNN - - -- - - - - - - --- AF T'ER --ABdUT_. T-WO NouRS W c- W iERE GtvE-W - - - _ -- - LL .tato M�CSM-oN. - - S t 1 CE-= W.A.S .. W tTNESS\kAcl 7-"IE - NSTRUCT CIA- -O-- MAN`/ OIF My FER-S�A L ._t 7EMS - - - (COMtSSAP,/) - -LE-C--AL MAT�RtAL x MET)\ CA L- _APPLIANCE - - - AND -ti1ID1ct&mm�,� _ -1� ATVEM PTIM -9::� -ADDR =: SES - - - - _4Y CON CB--Z, S-� C) �t✓su��oN ot=. -t�RO�ERT�I . - - -- D t-S rR C� M EN C t N E A�\I_D_ _M-CD 1-G.,-'t_ _ A vPPU -. Nc ES _ WAS-_ AG_A1 A C;; DESS CLERKS _� =T_uRt 'M- -i KE "OLD NG Ra)", - _AFR©utAD. .- -57P," OR. -M MY CHS PPDs -- - - - __ B SCAM E_ MORE C��CID� S G-o T TE{� AT i�'VIC \1 _ _ O'�: 7_1_E "PO - \"0 _ GAVE MS ,N Nk k RC� 7ABl_..=i; Dib NCST-- --CARC tF T- , WAS LbcKuP_ _ - - _CAS_E r-oR VERBA\_. AZ3 uS w E-- N VI/N i ES, Z "OW EV E-R - - - - Ate OFFICER - __ _M\/- COgCERN _T FELT' 7 E 1� URSE "(-)WEVER _-- COULD KCT- _G-__QE. -VIE _ My- - PRESCRtB b MEDtCAT1CAS _ - _- - Lt.Si F MN EN CJ-ilok�s --- - . SWVIIK, RLTA , _ - ----- _ --- - Ti-1-E SAR GIE _ AT V�o ACK�A CnI LEbc--E My - --_PRESENT,_COCA CIERNS_,_ __ET__ WA S tP __U -br b NkCS7 E:XtST, - -. CNANG-E- EITI-4 ETA EARUER - - OF r_A`c 'E.R-` _ 1�_ \T�s- _.WAS A\n/ARE SaN1ETN r qG WM- - - -- _-- -----pCFIt1ELY __vVUSE- _A r-IEW PR\-SOtAERS W KQ -- -- - - - - _ WAS _ R NALLy - .-PR( _ STI LL Na_ Mlnt_ciTrct4 , N oR - _ -t—,. 'TNE _ MEDICAL. M O.DUiE t CALLI-=p - - -vJ AS_- p-Lacm t kJ A ROOMG- - A _"UMM4- 13'i�1NG j _Much LESS A ANIMAL m _T-t� A . SA.T E Off= CM'PL-T . _-I Ln RCSS - - ._MAD OUT W-M-t _1- +MAN- - _WASTE/---URy __BLooD . I R i S CND MON WAS _ PR-EV CtEWF ON T�4 E _f_LCORSI WA LLS, MA T TRESS '�ND _ D ES K. ON GrRY . _ANID - i N PA\kA -_U WAS - - - - -ME� M oDULE Di=P UT,-/ _ - - - TC� _?ERM_I_T ME .. SAN_t-TA`BION -A D CLO�NiN_G- I=-QUtPT _ - --- _ OF TWE E CELLS _ -1,F_ 1 NS P_E CSD W C-\U LD MEET' MANDATE T"E SAN 1-TNT1 Oil - R u�R EN1 ENTs MAN\UATED 3� TTTLE 15J - I l_ - N1N t �U M- -SA`ND r�� - - - - - -O NLAL-.Z� --PR.OVIDE - PPOPE-R C�R REQUvR.ILD- - - - - - - - - - MED r CA L-TREATM ENT- - - ca1NCE M' -tN-CNFCEF�ATION_ AUGUST -\_� r_ V9q ,_Z -AAV W R V-n N.G-- AND V ERBALL-/ R EC� U E STF='D -Tz� S ES - - -- -- -_- THE - DOCTbR_ OR_._h.00TZLR_ ASS1STMA T, ALL -O.E 7-14ESE _ E�UES T _W-ERIE- MADE D 1 RCc.Zy Tb T14E -MobQ LG- 'NURSE _Wt t0._-ALN1oST UA\L-1 AFTER _ AUGUST' R_91 19(2 3 _- I N�LR M ED . -ME- - 7HAT I- -W PSS ON TN E S�CAIC CALL _ -LI.S . _ M _SEE_ TN_E t >URSE _ FRAcT1Ot.EYki s-Ev�N - - _- FkLED. A__ t-6RMAL_ .GPO Vh,NCE - -M) TkE N_UPSE . \/ -- - - -OrFkuE� ,_ . A . DAY -LAS AGAv1 l _ AMussv A- - - - -WAS _ .tA�--71AE-_L\ST 1b. SES_�E1 �OCTQ _ - - - - ASStS-t� CgSULTAT_lON - E i1 N -TH\WGki- .S - - - - WAS CCM`?.L-AA+0 cNC_ ABc�uT CH ?Ak1 AS (T�-t11-1R _NE! D ACNCS� _ PAtN ASSC�I,4TJ- W ITl-� - - _ - . - - - - . .EXCESSWC-: SWEILLNG LEFTSN)LLDtR_ A"'b .tAECK - - - - - NG-- �S-_sER1bLSL�ll W ROtAG)- - -- ___-- 'DR CARR C)"CE' An1�- - - --- ------ - - -AE . NURSP-_ PRACT-latm\Eta Cad CE - Cil -- -- -- T i _ S : WAS_- ,SEEN_ P-URSOANT TLN - - - - tTT _ �t'_AS _ _A_ MOR� _ t��T-_ t_�r t✓ _�T ZSR��Et�i N� _ �TF-E�`� _ Nis a nt_ . .: �_��nv-t✓---- ST��t� AND . TREATMEII T. _ _ � _��Oi l-t tNG . i�-�s �ccuRRED StNcE �-ic�ss�v4�s1Ts, -eVF_"_ AFTC-R__ R_EPEAT� MAD_ PRCNM SES. EV_El\i_iF- UGO__ STT AS Mog iTOR_ ON CE -AWE-EY AS 7NE NUMBER. _ BY A REs i�1 TEb_- _ SSD1U.M-l\SALT/ FAT/CtA0LESTRC)\-I HIGSA _.-- -_ Ft_BERREST_/ .'iECCRCi_S.T MAD 1✓I DtCA�at�_ . Nt)_ _CAREE u_L R_ El)i CA L NlaN rM'Ri 14 G / CA tJ A SAT --- --- - - R�SN i.N-t�►_� �.D_1� 1r: MAIM-TAN- A MC, A-I�hD M01\WMRED BY _LAW- -N-AS-- P1-ACE _,PETI 1 1 OK� - AT _R_LSl< MUS7 _ _0iGNE9_.THAq LE�.ALLy PERMISSA3i IN A _ p EMOCR ATl G MAS CAUSEI�_) _ STREESS/s RA\1J- \S PREY_ - _-- AND iTS- vIERY _ AcT IS CRUEL ANM SYN,USUAL _ -- -_-- - - PU N tSH IA N l. _T-A R - - - - - MANDA - S.'/ LAW. . - WAS Mcw IP-b _F-ROM _ N OT _ON T1A E_-CRD E-R-,S__.O R_ . - - PER-M\ \eN --OF- -THE 'D6CT�)R OR De)e`z>t�- ASS1 S77.�_NT -------____ - - -----1N_1-�0 ACBE_ MORE QUAL_ FA ED. -C1-i�t�1A_t�URS_C� S-7AF-F _. -_. .MEM BER . iT- I s To. sE N4TC�. N fk-T. - - _ --PURSUANT 70 _i�1E G U 1 DEL!gES AS AUTHOR\Z.E 61/ __AMlER-I.CAN- M- M1CAL. ASSOCI-A7oiA -TH-E ONLY .PERso� tMAT _CAN AUT(-{dRIZE P\El CASE- OF A PATS ENT FRONT - -- _NouSNG MEDICAL. PATTENTS - - -- ► _ A LP. NYS 1 CI Aq ; OR A DOOR, _.ASS\ST7v - - - - - L I c t N S_E ►N TI--I E. ST7-�1 I .O F CAU I - - -- My MCJICAL_ MN E WAS 10\14 EV ER _ 'EN M_ 7140004 ----. - - - --- _ T Nt UN M_ - CPUTY OF --- -- -- ---- - C�}�S �: -PAN DISCCMFCRTS SEE MESSAGE_ T IA 1 B \T - - - A77AC11 ECJ. - - -- A7\ -�ARLiR TkIAT 1'�IORNLtJ - - - - T.-WAS CLMPLANTE1 -tom_-_MORkANC-_ - SW FT u_RSE WW) &. ATED---i---HAD _m F t LL__OuT - A -ECov/PUED S COMP LEL-ED_ --AkAOTNER- M_E DI_CA L R E-q uFST- �EN IE� T N UG-N _T� Kt�_W IT WOULD CO Oil LINRESPCW-)ED - - -- PURSUEARU NG .CR- \kAS\S-nqC-- --To SES A -- -- - -- SSU L-m VN_ 1 EMCVA L FROM kAc Ul Is G t��t tT A t��4 _ LOCK SLP. --- - MEWA�_ SYMPTOMS - .WAS_ RAcNc-- (3R ExceLORATED - - -- \KVD TORI-� AD�C H E-A-7 PAt qs - - --- -- - ---- C)F-FtCER-/AORSIE ._W-M SE._ 0tALV .RATIONALE WAs-- IAA7 A`1TEM�11 NC- `M_ ADVo1D -A M�t�LE MOVE-. _ WAS D\J_E o�A t-y -TC) —E- CURR OAT OcAE CE-z�L[c*AE t•T tS- �o - C�iFFER_ N-7- -7\-A--.1Aq 71�Z- t�'XC ._ eAStCAIUy- _FILT_t-t\/._ _ - - AFTER `.T"le 7-H R_EAT- 0 A W R TE:UF/ S�GREGATtON _ -- - ---___-_GCKVP. ---� NtC-SV E . 'EN EN _THoUC f 1. _NO. OOk�StDERATICJO- - - - -- - ---- - `� WAS _ IF-CF _TZ�_'CA -Y A PPROY\ M RTELYl t�s- -- ----- -------__ __--- CSF_ LEGAL__MATER\ALS_/COMMISSARY ANAD P CMZ of SAL._ - - - VJAS _t=aRcE _R) _ _STAN CN0 S\DE FOR Ate -"OUR l -W EIS Nty _?pnPER-vv _ - - WA,,S R:E_SukRCA, AT--V-'L--R- ANc5\"ER - NoMR WAS 1_-CCK)E:b _ 1N A_ C1EtL ATTER 9EPEA= ComPLA1NTS -- _ OF D\Z_Zj t 1 FSS CRE-Si__. PANS_� TNC tAURS-E -WAS-- CALLED , - S�VERaL Nut�.SES ARR�vED it�tCLL�DtNE_ -1�-1E Ct-ASS1`C=icAilc��l _ _ -- - CSC=t-tcEF,\,- NURSE _W- Ho REPEA ELy WkS\S T ED THAT. T WAS F,4X\ AA I LLN CSS _70nK MY.. BLOM PR - 01� LL/ _H i C-4/ BUT- _TH_AT_ M y t-W�DS. WET/FCRENEAD of -___ _-- -_-.-- _-- - - -NART _P-Ro�3LEM> �tC IMMEbIA E -C AVC Mrr A Cit CER.tAED_ BE_cAUS E 7-HE X _ _ _ -- --- ---- _ -_ _KN_EW__ 714Ey - NAb MADS_ -A_ tNcoRRC-CT Ds�:CVStok/ Mov(Nc M E __Mce CLASS�F i cA to _O FRCER cO M M ENTF-D/ - A5 -_----- - t t= 1(- WAS_ A .CogSO A11 q E_c)t,1. -Mt= At4D _ �r - --— - --- - _ -W t LL MOVE-E_- You - N.-ME M CERN t N&. -_17-{i S WAS A _ 1N! OL-F/ _ALAN, M`/ ONLY( CvN CL-kN. W AS M-y tjEAL-M/ - - ----- --- _-AMCT_-A ,FEAS \GN Ml I-F OF- "GUS1t1G-, - - - - - - NURSt=S-- ARE ROE UIR_Eb -_M -MAKI- pectStC)Q/ MAgY __P M-E7S -- -- - - -- -. -I-ACKi N M ED-I CA L CbM PP�CE, - - - _-. I �iMATE .TO CGMPLAIN- ot= CHEST- P/NWS - - ---- - - P/NWS. -_WAS CGtVEN TYLENOL ANS -MLD-Z) Go� - - tS-_DEC�S\ON WAS \MAaE BY A QRsE_. _M US IN-MATE---C A.EEt) tAEVER _ REGM kC, - CNZGIC�OINESS, -- _ =RCN ICS. -1-N_IS _INMATE. D1� N THE SME CEtL T WAS _ - - - - - -- - - P_REV IO�3sLV _HbOSEL I N- H E _M L=DI CA L M CZU LE, - -- - _ _APFfRc)x,1 NIATEi-Y . -Wo PLUS YEL\CRS� "C)USE --- - -- - H E !-Nl--M A-R j I N.EZ f-T- -TbdK WAS TN"E -V t CT-[ M S MADS . BY_SEVETRAL �A URSES (IA AT" WAS -- - - ----- - PsIQ�-y �I-I=E-_"i��tREATE.\yi�\G_� OR McsT-- CRTA�NLy - - - A_ MEDICALLY- USASuNG. IW4E—SS/ ATTE14KED To XPERt I=NCA AND ROT - - _ OOM-REjAnATLV_ Q-I)ALI TIED- ___ tZ" MAKE/NOR PERM ITT"Eb ---- - - - -- -BY __LAW--T l__DU _Sod- --I F -LT_ WAZWIT"_FOR_-THE FACT -----;H AT__M.Y. GO N D cn_ctI - _\4OR SEI� t JG/ R u(R I NG IMME-DIAI--E= -Hr---)SPITAUZA�d-�-1/_ ITSA -RERSotA13LE- _M t CHT- -NOT la�E FI a nAG TNI S - - --- - - 0--OMPLI-�k-NT:_ -THlS MUS-I= S-mp �. _ TYLCNOL. DOES. Patient Namegyo DOB MR# Contra Costa County Detention Facilities SELF-ADMINISTRATION RULES AND PERMISSION TO CARRY MEDICATION 1. You are responsible for keeping your medication secured at each facility. 2. You are to take the medications as written on the edica ion package. �() Med/schedule (Z '_. Gr Cl'C��. Med/schedule t 3. Do not trade or sell your pills to other people. This can cause permanent damage or death. 4. If you have any problems with or questions about your medicine, notify the Deputy or nurse or put in a sick call slip. 5. If the FNP/MD changes your medication, you will need to turn in your old pills before receiving the new. 6. If you are released before you finish your pills, take them with you and continue to take them as directed until they are gone. 7. If you go to court vou_mav kean,_th=-nilly in your pocket with this permission paper,__ 8. If you do not follow these rules, you will be referred to custody. 9. There will be periodic spot checks by medical and custody. 10. If you want your medication renewed, put in a Sick Call Slip 3-4 days before you need more medication. Allergies have read and unders ntese rules and instructions. Patient Signature L UL Date Reviewed side effects an t ,indications. 2� Nurse's Signature Date _ you to carr � > SAVE THIS PAPER - It authorizes y Y the medicines listed until DET 054:FRM Distribution:Blue-Inmate;Pink - Medical Rev.2/8/93 Patient Name L U 0'"` r G hwv� DOB 2 �- - MR# 1 ' Contra Costa County Detention Facilities SELF-ADMINISTRATION RULES AND PERMISSION TO CARRY MEDICATION 1. You are responsible for keeping your medication secured at each facility. 2. You are to take the medications as written on the medication packa e. Med/schedule1r`o�o�, Med/schedule 3. Do not trade or sell your pills to other people. This can cause permanent damage or death. 4. If you have any problems with or questions about your medicine, notify the Deputy or nurse or put in a sick call slip. 5. If the FNP/MD changes your medication, you will need to turn in your old pills before receiving the new. 6. If you are released before you finish your pills, take them with you and continue to take them as directed until they are gone. 7. If you go to court, you may keep the pills in your pocket with this permission paper. 8. If you do not follow these rules, you will be referred to custody. 9. There will be periodic spot checks by medical and custody. 10. If you want your medication renewed, put in a Sick Call Slip 3-4 days before you need more medication. Allergies N, I have read and understand thes ules a d instructions. 1 Patient Signature )Io` = Date Reviewed side effects and dontraindications. C1 Nurse's Signature Date SAVE THIS PAPER - It authorizes you to carry the medicines listed until DET 054:FRM Distribution: Blue-Inmate;Pink -Medical Rev.2/8/93 - _DE- S-iIR UOU N OF _ (WMATES__. PROPlEkT`/ -- MEDi CAL_ ADPL\Ake CE, AND SO PP_ ES �`9 i DURI N C-, _A L�N&_My_ _ LSoo\<t N C-- PERSO N A L_ PRO PERT`// _FLEM O N ES/ M ED\CA.L -- -_ __-- _ - _ 5UP`�LiES -A-ND .LEC--AL SUPPU_tS _ WERE CoNSF\CAt�� ---- --- -- - - AND . 1�_1S ROYF- IT ESE --\TEMS- _WERE - NOT-- - -._ ___CONTRABAND AND PO-SED NO SG'CURIT\/_. -M Ri =AT• - -.SSW _Mo_l_H PASTE H5 ,-- 2_1�0 - -- — – – �� -- CA_N\A\L CUPPEPS_ .c�O - - --- -- - - C�) C -M-B -PICK_ - 05� - - --CU(_ M •(05 -- - �7� -- POS- _CF CLI} - 85 3,40 Q> \-OU\.S1 =r1©T_ SAUCE \ . 0- 'M 0 -- C`1} MCD(CATER FOO-F P_OWbED R __ - - - - - - PE-RGLEum Spy SE L STY U N G- ,2-5- - (12� 1.60 _ C3) _ –N.I TROG L`-CER 1 N .f . - _ 50IT E tc c> is N KNOWN LEC-T–. _.ARM \ MST'_ _SUNG x_ LA R-CE 4!5M •- - _- - COLD_ PAcKs ----- - It�ISi D- Cj PLAGNG—_ X115 PR�PERT�I l_N._ A PFc� PEKV',-J - - _-BAG .- _BE 1F_E7uRN Tc PRkSn1ER UPON RELEASE AS T-�E.40A-R'Efl_ . BY LAW / B.00QK AG CLERK T )OK- - . _ - -- -- AT C-vEN - - - IOu�N SAip ..IT—O-\AS_ WERE PERM ITf D 1�A AtAO-k1-1Ep\ - - -- - PE-Ri1.6N.ER WAO, FA_R_to WLARL`l CON CERN A_ WA.V i SLt N_G ..TNA R �EA�Es_-PRcss�RE -_- _-- __-- ANIS _ EXC�StV..E. WEIGNT. SUPPC�l� 1`�D W 6NUt`LDER . NuRS� AFTER VIASPEck tcN- T kA -- -____- _-- -- _- - - S/\M -,SLruE WAS PERMtsSABLE/ OF'FACER ATS 1-IA-F Pc k -i-aSS SAt D ACROSS . SA-lb VlTnAOUc -FEP.LAOt AC-- SAkb SUgG ttA PRrSNER - - - PETITI©qER HAS 'REPEATEL`/ Rte,\3Es�D F= LE SL RVERAL DC _1 k _ATT7�C1- F-D-, -- AT _HAS r3 EE'N A PFPCS 1 MATELY 7Wc M OWT�S� - A N'I-) A L .REP EA i r� R��E�S - �c�t�� W RI _ - - SAME S= ESPQNS�� tt �i�l_ Ol�l7ERu - - - Tr4 tS_-- �5 SRU Crt ON_ A t D _ r Al LU R I _-FC) RIEPt_ACE---- -- - HAS CAUSE PETM0tAER . U R 0 CCE�-:SARY --TAi�i� - ZMdTtONA�-- D1S�TRES At,�D _ DiS COMFOR_i 1 7S- LOSS S-LOS \-FAS 3-ECPAtZDiz.T-- PET--nogER AaWTY -- - - :T3 -R-CCCAER CR MAY CAUSE DELAYS C)R, _ 'FL td t WR M EDA CAL- -CCOP:L1 CATIONS --`HAT WCU LD -FOR- PRO F�ER_J`/ -- - --- - -- - - - - - - - --- - - - ---PENAL -----____-- -- _R C El FT_._FOR-_PROFCRTY 7AKE�A. --C=RAM- ?�US.ONtR int HCN.E_V_El _ A VA -- tnl-E/-\PO�A_.-OR CYM_ CR_ FERSC� _P-ROP E RT_/ \S _LAI _DA. 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ASSLMES - t-\AIV E ._5CO-10 - - REQURCz _77D.-A CCNSUt�t_�R Ott THE - 7"A RD_; \tJ N ETH SR -ni 1 S 1 S _A N-- OV ER `TSA E_ - ----- _ ccuk Tv_— R _ DRUG/ IT 1-S A .0FUG__--V_A4Xt_ \N AN ----.ti N.S.T t TU T I GN St-ta U W E COW1 bt_t_S\i E - V\SED_ -- ABUSE t-S av ER W 4EU4 NG - WRTn:, PUB:-L.iC SA --U: l . T"F SATE Y _C)F _ i NMAT S SKbUU) BE_FIRST Cc�NS�D - _EF�R� Ba'C'�GE:T CCVAC�:RNS C)F PRoV-I Fs, PC)BoTusskt� - __ - _ CON INS ALCCMOLj OVER USE CSF TYLC-DIOL_ OR _.CFVR/ OR . AW,/ CDM Bi. NAP O bF ANY CSR. /-\LL T(-1 E CSVER T-R_E- - - - _ DRUc� CAVAlAAviF_ MtWD __ALT7=RtNc- _M--eCrS__- - iA1«N WMT 0\_ST SUPER\ lStoq. CCNULI_') PuACC ----- - - -- -- STAli--TV:_/__CCUS - P svNN 1_�vts�TbRs -� -VVlE INMATE - - - - -- - - - _CSR LLCM -_LNMATF-S Ar UNACC,E t t3LE .R1S_K_LZ C-�S. - - - - -- - - -- ---- T-i F 14 TH E_ S.ELL AND k_ S P - \LSE _ Atl_ - - ------- - _-_--- -. - -aTAlADAPIS� ..MT[TU`Tl QN _SECURE t V- _R E-GU_ ATl8N5/ - - - -- -- __ - -- - -- - S1 xq-14R bSSESs_tQN -- OF -17W_ENS/_ _-T`(t_E-NaL - - - CUE-P, T-t E couN T ER_ `DRUG \S - - - - - - _ - ___ - - -- - - -____-- :IT'_ pCSTENTIAL _FOR _ AC3\_�SIE7_-AND µ EM._CNTb- -- - tNsT--WnIN REGULATE .CONGA- - _ ------ ___- . __ QA-ND--- -D1 UG-S --MAD Tl-IEN PeRMIT T4 -E Sc-LL. OP D-RUGS - - '�' - -- -MAD __S--kRC,SS- -1_Eti'L=LS ARE_ ,ALR EADV - AT IAOCCEP 7 '� _LEN E LS , _ W H y_ -,.BAND A i t�11G- PEN C=OR SECU(�t�j C� ASat�1S-- -WJA iC'\A-- ' T . MAKE SENSES *,A-l-4ElA - - - -- - - - - - - -.'RCVERSE--- -A --MA-S.0 - -'PRbakA-:W ANb__CbNCERq CDRUG,,� - - - --- - - -- - - T uE�S-E DRUGS .-CAN. C3T=- 'DAMA-VGS L\TaRY .MAW.N =-R . 1141S VIAS -- - - - - - -- -- - --- -"lC-.W CA L-_STAFF S"(SuLD — ---- - --- -.ACQ._r-11MST- --cttkS- SELi . M EMCATtc)N t�ROGRAM , V MODULE ROOM NO. CONTRA COSTA COUNTY DETENTION FACILITY COMMISSARY ORDER FORM Name(Please Print) LAST FIRST MIDDLE Booking No. Sign Here Sign Here Date-/-/- When Ordering X When Received X NO REFUNDS • $75.00 LIMIT • NO TRADES ITEM QTY COST TOTAL ITEM OTY COST TOTAL ITEM I OTY1 COST TOTAL SOUPS CANDY MISCELLANEOUS 01 Inst Lunch•Beef .80 51 Breathsavers .60 742 Ball Cap 4.85 Inst Lunch•Chicken .80 52 Lifesavers•Five Flavors .6D 743 Insulated Coffee Mug 2.50 Inst Lunch•Cajun Shrimp 80 53 Baby Ruth .60 744 Pencils(Set of 5) 1.00 Inst Lunch•Chili .80 Butterfinger .60 745 Colored Pencil Set 3.30 Inst Lunch•Cajun Chicken .80 Granola .60 746 Sunglasses 4.50 Inst Lunch•Texas Beef .80 Hot Tamales 60 748 Address Book 2.95 02 Dinty Moore Beef Stew 2.50 Kit Kat .60 749 Dictionary 4.25 04 Top Shelf Lasagna 2.80 M&M Peanut .60 750 Writing Tablet 5x8 1.00 05 Top Shelf Spaghetti 2.80 Mars Almond Bar .60 751 Writing Tablet 81/2x11 1.00 06 Top Shelf Salisbury Steak 2.80 Milk Way Dark .60 752 Drawing Tablet 12x9 3.20 07 Oatmeal Map&BrnSug(5pkt) 2.00 Nestles Crunch .60 775 Envelopes,Std.30pck 1.50 08 Chicken Broth 8 pkt 1.50 Pay Day 60 753 Bandana 2.75 09 Beef Broth 8 pkt 1.50 Reese's Peanut Butter Cup .6D 754 Greeting Card Birthday 1.50 Snickers .60 755 Greeting Card Friendship 1.50 DRINKS Three Muscateers .60 756 Hair Brush(No Handle) 4.50 21 Hot Chocolate(Spkt) 2.00 54 Red Licorice Vine .75 757 Hair Net 6 each 1.20 22 Fruit Drink Mix Opkt) 1.50 55 Halls Mentho-Lyptus .80 758 Hair Ties 3.80 23 Tea w/Lem Or Mix(5pkt) 1.50 56 Butterscotch 1.10 759 Ladies Pantie Small 2.90 24 Orange Drink Mix Opkt) 1.50 57 Jolly Rancher Assorted 1.10 760 Ladies Pantie Medium 2.90 25 Lemonade(5pkt) 1.51) 58 Sour Fruit Balls 1.10761 Ladies Pantie Large 2.90 26 Decaf Coffee(3oz) 3.25 59 Tums .85 762 Shower Cap .40 29 Coffee Break Kit(5pkt) 1.50 OVER-THE-COUNTER MEDICINE 30 Columbian Coffee(3oz) 3.25 HYGIENE SUPPLIES 764 Antifungal Crm 5oz. 7.80 27 Apple Juice8701 Irish Spring Soap 5oz 1.20 765 Aspirin 24 each 1.75 28 Cran Grape Juice 8q0 = 702 Ivory Soap 4.5oz 1.00 766 Chapstick 1.30 SNACKS 703 Palmolive Gold Soap 4.5oz 1.00 767 Hydrocortisone 1.56z .65 301 Beef Stick .65 704 Dove Soap 3.5oz 1.80 768 Ibuprofen 16 each 5.75 302 Beef Stick,Hot .75 705 Soap Dish,Box .85 769 Multiple Vitamins .90 303 Sunflower Kernels .65 706 Protein 21 Shampoo 3.30 770 Quinsana Med Foot Pdr 3oz 4.00 304 Calif Natural Mix .65 707 Balsam Prot Cond 12oz 1.30 771 Robitussin 4 at 1/3 oz ea 3.20 305 Peanuts .65 708 Balsam Prot Shampoo 12oz 1.30 772 Sudafed 16 tablets 3.20 306 Beef Salami 1.50 709 Comb Thru Softner 10oz 5.95 773 Sunscreen loz 2.50 307 Carmel Corn 1.50 710 Creme Moisturizer 3.30 774 Tylenol 10 ea-chl 1 4.00 308 Microwave Popcorn .90 711 Styling Gel 3.20 309 Sharpey Cheese 2.00 712 Dandruff Shampoo 12oz 1.30 WCDF&MCDF ONLY: 310 Cheese'N Jalapeno 2.00 713 Sulfur 8 2oz 3.25 Six Pack Soda 311 Chocolate Pudding 5oz .75 714 Pro 39/Pomade 4oz 3.25 91 Pepsi 4.20 312 Tapioca Pudding .75 715 After Shave 4oz 14.5D 92 Diet Pepsi 4.20 313 Kosher Pickle 1.00 716 Brushls Shave Crm 4.75oz 93 Orange 4.20 314 Bag OTabasco Sauce 1.10 717 Gillette Razor(each) 94 Mountain Dew 4.20 315 Hot Nuts 1.10 753 Shick Razor 316 Pork Cracklins 1.10 718 Magic Shave hoz INDIGENT HYGIENE 317 Pork Cracklins Hot&Spicy 1.10 719 Baby Oil 4oz 1.30 LESS THAN $2.00 BALANCE 318 Cheese&Crackers .70 720 Body Lotion 12oz 1.30 319 Peanut Butter Crackers .70 721 Baby Powder 4oz 1.40 81 TOOTHBRUSH 321 Cheese Dip 1.50 722 Cocoa Butter Lotion 12oz 1.30 82 TOOTHPASTE 329 Jalapeno Cheese Spread .50 723 Lady Speed Stick 1.5oz 3.90 83 SOAP 322 Mini Donuts 1.10 724 Mennen Speed Stick 2.25oz 3.80 84 COMB 323 Brownie 1.10 725 Noxema 4.5oz 4.50 324 HoHo's 1.10 726 Petroleum Jelly3.75oz 1.90 Signed 325 Mini Muffins 1.10 729 Mouthwash hoz 3.20 326 Cinnamon Roll 1.10 730 Toothbrush 1.00 Commissary Form 327 Fruit Pie 1.10 731 Toothpaste Close-Up 2.7oz 1.65 CHIPS 732 Hair Pick 1.60 Must Be Returned 41 Chili Cheese Chips .60 733 Massage Brush 2.00 To Canteen Office Cheese Puffs .60 734 Pocket Comb .80 BBO Cornnuts .60 791 Kotex 3.25 Cornnuts Chili Picante .60 735 Foam Cushion Rollers 2.00 BALANCE FOR OFFICE USE ONLY Cheeze-It .60 736 Massengil Douche 3.25 Gardetto's Snakens .60 737 Tampax/Tampons 2.65 STAMPS Pasta Snack .60 738 Lipstick-Pink 2.05 COOKIES 739 Lipstick-Red 2.05 Grand Total 61 Vanilla Wafer .70 740 Make-Up 8.00 62 Raspberry Cookies .80 741 Emery Boards 1.20 63 Shortbread Cookies .80 Effective 8-93 64 Club Crackers 1.65 POSTAGE 65 Duplex Sandwich Cremes 3.25 90 Stamps(Book of 10) 2.90 • We reserve the right to limit orders. . Fill in all extensions. 66 Soft Batch Cookies 3.25 900 Env.,Legal Stamped 5pck 1.75 . This order subject to posted commissary rules. 67 Oreo Cookies .65 1 1 1 . Prices are subject to change. it DCJ w i�7 tiJl"-• h- 1r9 /TfD LJ Ln M f? =d 1� c Q Ip Co 't7U11 a o, vi . i �ej Gv CLAIM G�� OCT BOARD OF SUPERVISORS OF CONTRA COSTA COUNTYCALIFORNIA5 ni i �T/ I IfiiSSF Claim Against the County, or District governed by) �BOARD,rA�CTfl10� the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT OVEMB ER 9, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $453.53 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: PALLOTTA, Carol ATTORNEY: Date received ADDRESS: 417 Harris Ave. BY DELIVERY TO CLERK ON October 12, 1993 (via. Risk Mgmt. ) Rodeo, CA 94572 BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 15, 1993 ppHHIL ATCHELOR, Clerk DATED: BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of SupefvIlsors ( 14,This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ) 993 BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (A� This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:Jr1d,y,jJ, , q /9 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California. postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: ,Q /_ Q /_rj q BY: PHIL BATCHELOR by. a Deputy Clerk CC: County Counsel County Administrator y y k CLAIM ? i. ; . t 519903 �� {; r� ��;T � BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA E Claim Against the County, or District governed by) ` BOARD ACTION y the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT �—!OVEMB ER 9,19_93 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $453.53 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: PALLOTTA, Carol ATTORNEY: Date received ADDRESS: 417 Harris Ave. BY DELIVERY TO CLERK ON October 12, 1993 (via Risk Mgmt. ) Rodeo, CA 94572 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 15, 1993 IVIL Deputy DR, Clerk V 100, II. FROM: County Counsel TO: Clerk of the Board of Su sors ( G/r This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ) 9`13 BY: AL,, Deputy County Counsel .III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ,'I' This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for ' this date. Gated1 /993 PHIL BATCHELOR. Clerk. By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California. postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 1 0 BY: PHIL BATCHELOR by Oe uty Clerk CC: County Counsel County Administrat r Clair to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th dayafter the accrual of the cause of action. Claims relating to causes of action for -death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code- §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal_ Code Sec. 72 at the end of this form. RE: C1 im By ) Reserved for Clerk's filing stamp Ta f RECEIVED Against the County of Contra Costa ) OCT 121993 or ) CLERK BOAR®OF SUPERVISORS District) CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 5� ,S 3 _ and in support of this claim represents as follows: _m________m s __p_m___m__mm_m_N_am_m_-_NmmM_m__Nmm-NmmNmmm_mMmO_s__smmms 1. When did the damage or injury occur? (Give exact date and hour)2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part df county or district officers, servants or employees caused the injury or damage? � � � \� Hyl � l'� • 7. Wnat are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim re d e full extent of injuries or g j y suite ? ( j damages claimed. Attach two estimates for auto damage. t ------------------ 7. How was the amount claimed above computed? (Include the estimated amount .of any prospective injury or damage.) = ki -----_------_ 8. Names and addresses of witnesses, doctors and hospitals. 9. List thb expenditures you made on account of this accident or injury: DATE ITEM AMOUNT - Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney Claimant's Signature W 1 "�CO.0S G_,A 2. �r� (Address) Telephone No. Telephone No.�SDf 10'�� NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or .officer, or to any county, city or district board or officer, authorized to allowor pay the same 'if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. l Gree-c� i 329 B _ A _ F _ COMPLE T E AUTO CARE 2218 Market Street San Pablo, CA 94806 (510) 233-1448 Fax: (510) 233-7531 Visible Damage Quotat� oa #129 by SAM on 10-07-93 CAROL PALLOT TA 417 HARRIS Style 2DOOR Insurer . Lic. Plate: 2CZSO45 Adjuster : RODEO, CA 94572 Paint Code: Appraiser: Phone: 799 4680/ Prod. Date: Claimant : 84 CHRYSLER LE BARON Profile STANDARD Insured . VIN: Deductible: 0.00 Policy # : Mileage: 10574 Claim # . Options: # Labor Op Description Price Labor Paint Labor Group Price Group 1 REPAIR L FRT DOOR SHELL 0.00* 3.0* 2.3 BODY EXISTING 2 R&I DOOR HANDLE 0.00 0.5* 0.0 BODY 3 STRIPE TO MATCH 16.00* 0.5* 0.0 BODY * NEW 4 ADL OPER CLEAR COAT 0.00 0.9 0.0 REFINISH * * Judgement Item Summary BODY 4.0@ 50.00 200.00 PAINT MATERIALS 70.40T NEW 16.00T REFINISH 3.2a 50.00 160.00 Non-Taxed Labor 360.00 Taxed Costs 70.40 Taxed Parts 16.00 Tx 8.250% 5.81 Tx 8.250% 1.32 Labor ( 7.2 hrs) 360.00 Add'1 Costs/Materials 70.40 Parts 16.00 Tax 7.13 Grarncl Tot a l 453 S13 **********************PART PRICES SUBJECT TO INVOICE******************** All Workmen Ship is Guaranteed For As Long As You Own Your Vehicle.. All Parts Guaranteed As Per Manufactures Warranty. Any Additional Repairs or Supplements Relating To This Loss Should Be Brought To B.A.F. For Further Repairs Or All Guarantees Are Void. ESTIMATE AUTHORIZED BY DATE Thank You For Coming To Our Shop For Your Repairs. EstiMate CX is a trademark of Mitchell International Copyright 1991, 1992 ALL Rights Reserved J CLAIM t� L 1 51993 5 . 11 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA COUNTY COUNSEL MARTINEZ,CALIF. Claim Against the County, or District governed by) i�D ACT'I0 the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT NOVEMBER 9, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Mount: Uhdetermined Section 913 and 915.4. Please note all "Warnings CLAIMANT: FLORES, Christine M. ATTORNEY: Michael Brooks Carroll Suite 1250 Date received ADDRESS: 180 Montgomery Street BY DELIVERY TO CLERK ON October 14, 1993 San Francisco, CA 94104 certified BY MAIL POSTMARKED: October 13, 1993 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 15, 1993 PpHHIL BATCHELOR, Clerk DATED: Blf: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supe sors (-V'*) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: . 9% 3 BY: / Deputy County Counsel 1II. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. p Dated: PHIL BATCHELOR. Clerk, 8y i( ( Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina See reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez. California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. n�l Dated: �,orn.t°,r�r /d_T /99 3 BY: PHIL BATCHELOR by 9 ,, ��lr Deputy Clerk CC: County Counsel County Administrator V. - Claim OF SUPERVISORS OF CONTRA COSTA COUNTY URIGINAT INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property orgrowing crops and which. accrue -.on or after January. 1, 1988, must be presented not later. than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action.. . (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at. its office in Room 106, County Administration Building, 651 Pine Street, Martinez, .CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than. one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code See. 72 at the end of this. form. * * �t `.. ' RE: Claim By ) Reserved for Clerk's filing stamp Christine M_ Florey RECEIVED E® ) ,z Against the County of Contra Costa ) OCT 1419M or ) District) G.ERKB NTRACOSTACRD OF OVISORS Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ in excess of$6,334:,40and in support of this claim represents as follows:, 1p = us interest rne alties&attos'fees allowed by law. --- ----------------- ----------- -------- N... N --- 1. When did the damage or injury occur? (Give exact date and hour)Wrongful act occured on or about 8/31/93, when upon-claimant's 8/27/93 demand for entitlements by her attorney, the Office of 'The.Sheriff-Coroner replied by still withholding payment due claimant. 2. Where did the damage or injury occur? (Include city and county) Claimant worked at the Richmond division jail of the Sheriff-Coroner's office in Contra Costa County, California. ------------------------------------------------- ----------------------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) The Sheriff--Coroner's office has been withholding last payroll and vacation entitlements due Mrs. Flores upon her resignation on January 12, 1992. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? The Office of the Sheriff-Coroner of the County of Contra Costa is withholding last payroll and vacation entitlements owed former Deputy Sheriff Christine M. Flores. (over) 5. 'What are the names of countor district officers, servants leemployees causing ' the damage or injury? Tom Young, Chief of Management Services, County of Contra Costa, Office `gf, the' Sherif f- Corone -- - 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Claimant incurred additional expenses in attempting to get payroll and vacation entitlements paid out by the Sheriff-Coroner's office. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Last payroll and .vacation entitlements: $5,134.40* and items listed under paragraph 9. *plus interest, penalties and attorneys' fees as allowed by law i -----_------------------ ------ ---------------- 8. Names and addresses of witnesses, doctors and hospitals. N/A i ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: .. DATE ITEM AMOUNT Jan. 12, 1992 travel/telephone costs incurred by in excess of $200.00 to present claimant in- attempts to-.--collect entitlements prior to rettaining an attorney ` Pov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some personon his behalf." Name and Address of Attorney LAW OFFICES OF MICHAEL BROOKS CARROLL Claimant's Signature Michael A. Hand, Esq. i 180 Montgomery St. , Suite 1250 20574 Avenue 164 San Francisco, CA 94104 Address Porterville, CA 93257 Telephone No. (415) 788-7600 Telephone No. (209) 781-6330 i N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or .district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($109000, or by both such imprisonment and fine. LAW OFFICES OF MICHAEL BROOKS CARROLL TELEPHONE SUITE 1250 c41s)7tftf-76U// FAcsll% r F 180 MONTGOMERY STREET (415)421-7379 SAN FRANCISCO, CALIFORNIA 94104 » » » T R A N S M I T T A L M E M O R A N D U M « « « TO: CLERK OF THE BOARD OF SUPERVISORS CERTIFIED MAIL FROM: IJICHAEL A. HAND, ESQ. NO. P-907.940 751 k DATE: OCTOBER 13, 1993 �� "` RECEIVED RE: CHRISTINE M. FLORES OGT 141 OUR FILE: 930012 " ROARnmnVISORS WNTRA s. COSTA CO. ENCLOSED PLEASE FIND: ORIGINAL AND ONE COPY OF CLAIM BY CHRISTINE M. FLORES AGAINST THE COUNTY OF CONTRA COSTA. PLEASE FILE THE ORIGINAL AND RETURN THE FILED ENDORSED COPY TO OUR OFFICES IN THE ENCLOSED STA24PED SELF-ADDRESSED ENVELOPE. THANK YOU. FOR YOUR INFORMATION AND FILES FOR YOUR APPROPRIATE ACTION XXX FOR YOUR REVIEW AND COMMENT FOR YOUR APPROVAL PER YOUR REQUEST PLEASE SIGN AND RETURN PLEASE CALL ME OTHER: LAW OFFICES OF MICHAEL BROOKS CARROLL By:_ Zzt�ee--1 Soussan Al zkoor D:\DOCS\F\ORMS\TRANSMIT.MEM n cr- p LLJ LU U pe. to c: d p W + V Cc P4 H ui +� m 4: H cn Ln Ln W Cn N m H N H �a v1 ® Ln w0 G N ri r H P-, O J a O v1 cd O Ir a lia� � fm!! J J c Q U y O o O w d 3 c z L. s CO u Q � � U_ � i 1 1' O CT 1 51993 CLAIM �l L�4 ;i 6' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA COUNTY COUNSEL iI Claim Against the County, or District governed by) �BQARD� ACT=ION`�L�'� the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT NOVEMBER 9, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $100,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: JOYCE, Michael ATTORNEY: c/o Betty Joyce Date received ADDRESS: 128 N. Humboldt St. , Apt. 21 BY DELIVERY TO CLERK ON October 13, 1993 San Mateo, CA 94401 BY MAIL POSTMARKED: October 12, 1993 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 15, 1993 JAIL Oepuiy OR . Clerk I1. FROM: County Counsel TO: Clerk of the Board of Supervisors ( 11'r This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: d, (S S'3 BY: Deputy County Counsel 1I1. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ✓) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DatedJJMM yyG(x t, 91993 PHIL BATCHELOR, Clerk, By �(_^,a -1011 A Deputy Clerk WARNING (Gov, code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned. have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:1?MN,ya, ,,_ /D BY: PHIL BATCHELOR bydDeputy Clerk J . �2 , � CC: County Counsel County Administrator a° RECEIVED BELLY CqLiCE �. aoyQE 3124 l�enjamin 1�aiuF OCT � 3 � �ie�ZmoncL, eaLl f oznta 94806 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. 1 /� c � CLAIM AGAINST GOVERNMENT ENTITY, STATE .OF CALIFORNIA COUNTY OF CONTRA COSTA SHERIFF:' S DEPARTMENT TO: BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA CLAIMANT 'S NAME: MICHAEL JOYCE CLAIMANT 'S ADDRESS : c/o Betty Joyce , 128 N . . Humboldt , Apt . 21 , San Mateo , CA 94401 PHONE : ( 415 ) 342-1366 AMOUNT OF CLAIM : 100,000 .00 ADDRESS TO WHICH NOTICES ARE TO BE Betty Joyce SENT: 128 N. Humboldt Street , Apt 21 San Mateo , CA 94401 DATE OF OCCURRENCE: May 4 , 1993 10 PLACE OF OCCURRENCE: CO3VTA6 <�15 r11- w�T �(GffMor�D� _ � County jail ,q, r , California HOW DID INCIDENT OCCUR: 7 • Claimant was assaulted and brutally beaten by inmates while encarcerated in the- county jail . The claimant was not provided the protection required by state and fedearal law. The acts of the county and its agents , was reckless , grossly negligent , and in intentional disregard of claimants rights . The county and its agents acted in such a manner as i rease the 1 ' kely hood of injur to complainant. 5 (-Rc u,6-, ledL 9} R'Fru.s&D 1J COcc/V✓ 6t Alt-) �R S Ts ez Ts �U ITEMIZATION OF CLAIM: damages unknown at this time , DATED: / G' ) a q , 19 e k� OILY per(/ a c p COWDERV Power of Attorney (General) i 1 i i i s Power of AftWmey (General) Notice: The powers granted by this document are broad and sweeping. They are explained in the Uniform Statutory Form Power ofAttorney Act(California Civil Code section 2475-2499.5,inclusive.)Ifyou have any questions about these powers,you should talk to a lawyer. This document does not authorize anyone to make medical decisions for you.You may revoke this Power of Attorney if you later wish to do so. Requirement For Validity 1. You must be a California resident who is at least 18 years old,of sound mind,and acting of your own free will. 2. The individual(s)you select as your agent and alternative agents to make decisions for you must be at least 18 years old and must NOT be: a. Your treating health care provider; b. An employee of your treating health care provider,unless the employee is related to youby blood,marriage,or adoption; C. An operator of a community care facility or board and care home.(Community care facilities are sometimes called board and care homes.If you are unsure whether or not the person whom you wish to select operates a community care facility,you should ask that person.) d. An employee of a community care facility or residential care facility for the elderly,unless the employee is related to you by blood,marriage or adoption. 3: You have talked with the individuals you have selected as your agent and alternate agents and,these individuals have agreed to participate. (You may select someone who is not a California resident to act as your agent or alternate agents,but you should consider whether someone who lives far away will be available to make decisions for you,if,and when, that may become necessary.) 4. You have signed and dated this form. 5. You have had the form properly witnessed: a. You have obtained the signatures of two adult witnesses who personally know you. b. Neither witness is:(1)your agent or alternate agent designated in this form;(2)a health care provider,or the employee of a healthcare provider;or(3)a person who operates oris employed by a community care facility or residential care facility for the elderly. C. The witnesses are not related to you by blood,marriage,or adoption, and are not named in your will or so far as you know entitled to any part of your estate when you die. d. You have had this form signed and dated by a Notary Public. 6. You have given a copy of the completed form to those people,including your agent and family members,who may need this form in case an emergency requires a decision concerning your estate. If You Change Your Mind In order to revoke all or a portion of this form,you will need to do the following:(1)Complete a new form with the changes you desire;(2)tell everyone who got a copy of the old form that it is no longer valid and ask that copies of the old form be returned to you so you may destroy them; and(3)give copies of the new form to the people who may need the form to carry out your wishes as described above in number 6. If, after reading this material, you still have unanswered questions,you should talk to a lawyer. Warning To Person Executing This Document This is an important legal document. It creates a Power of Attorney.Before executing this document,you should know these important facts: 1. This document may provide the person you designate as your agent(the attorney in fact)the power to dispose,sell, convey,and encumber your real and personal property. 2. Your agent must act consistently with your desires as stated in this document or otherwise made known. 3. This power is subject to any statement of your desires and any limitations that you include in this document. 4. You have the right to revoke the authority of your agent by notifying your agent orally or in writing of the revocation. 5. This document revokes any prior Power of Attorney.. 6. The powers granted by this document will exist for an indefinite period of time unless you limit their duration in this document. 7. These powers will continue to exist notwithstanding your subsequent disability or incapacity unless you indicate otherwise in this document. 8. You should carefully read and follow the witnessing procedure described at the end of this document.This document will not be valid unless you comply with the witnessing procedure. 9. If there is anything in this document that you do not understand,you should ask a lawyer to explain it to you. 10. Your,agent may need this document immediately. Either keep this document where it is immediately available to your agent and alternate agents or give each of them an executed copy of this document. "" "-"--- -`-`•^_••'-^•^^-•+^• ..n,ot.e.ansamnm and m no way acts,or is intended to act,as a substitute for the advice of an attorney.The porter does not make any ]Power of Attorney (Gi ral) Know All People By These Presents: 1.That.......M.t.G.k,.Ix-.C..1.,...........D........!.G.:`:5.. ............................. ..of........................................................... .. Cityof...................................................................................... County of.............................................................................., State of California,hereby appoint(s) ........ ........ .tl.N.� ..................l..a.Ff of.......... TLC.C..........................................................City of....................................................................... County of.. .... .a,.n�........ l rte.. .s~..............................State of California, my true and lawful attorney in fact for ............t .:.r-...L,.a.. ....�.........L)........J. ........ and in..........1�.1.a..>~..1�..�,.� ..........A:.....Jap..:?,...name,place, �and stead and for ........ . ,. c�..la..y,,..e..!�f............�......:x. :�.c ......... use and benefit: (a)To exercise,do,or perform any act,right,power,duty,or obligation whatsoever that..... ,............. now have or may acquire the legal right,power, or capacity to exercise, do,or perform in connection with, arising out of, or relating to any person, item, thing, transaction, business property, real or personal, tangible or intangible, or matter whatsoever; (b)To ask demand,sue for,recover,collect,receive,and hold and possess all such sums of money,debts,dues,bonds, notes,checks,drafts,accounts,deposits,legacies,bequests, devises,interests, dividends,stock certificates,certificates of deposit, annuities, pension and retirement benefits, insurance benefits and proceeds, documents of title, chooses in action, personal and real property, intangible and tangible property and property rights, and demand whatsoever, liquidated or unliquidated,as are now,or shall hereafter become due,owing,payable,owned or belonging to................. ..;:L..li.rt.e..�.......� aw...or in which ......{.h....r... ..c. . ......J.a '4C..t................ have or may acquire an interest, and to have,use, and take all lful ways and means and legal and equitable remedies,procedures,and writs t , in ...........^4-10--(.... .. ............... .: .. ...:....................................... name for the collection and recovery thereof, and to compromise,settle and agree for the same,and to make,execute,and deliver for .... ................ and in .........(3.t:..T.t. .......:!.a.. t..x... ..................................... name all endorsements,acquittances,releases,receipts, or other sufficient discharges for the same; (c) To improve, repair, maintain, insure, rent, lease, sell, release, convey, subject to liens, mortgage, and hypo- thecate, and in any way or manner deal with all or any part of any real or personal property, tangible and intangible, whatsoever,or any interest therein,which ....... ...........ci.: c.. ..................................... ......now own or may hereafter acquire,for......... ....... and in............:................................................name, and under such terms and conditions,and under such covenants as attorney shall deem proper; - (d)To engage in and transact any and all lawful business of whatever nature or kind for ..../`:.t.G..G••�- e.• ••••••••• .............J e.......................... and in ...................................................................................................:.......name;and (e) To sign, endorse, execute, acknowledge, deliver,receive, and possess such applications,contracts, agreements, options,covenants, deeds,conveyances,trust deeds,security agreements,bills of sale,leases,mortgages,assignments, insurance policies,bills of exchange,notes,stock certificates,proxies,warrants,commercial paper,receipts,withdrawal receipts and deposit instruments relating to accounts or deposits in,or certificates of deposit of,banks,savings and loan or other institutions or associations,proofs of loss,evidence of debts,releases,and satisfaction of morgages,judgments, liens, security agreements, and other debts,and obligations, and such other instruments in writing or whatever kind and nature as may be necessary or proper in the exercise of the rights and powers herein granted. 2.Granting to .....�t."r- :........!?......J.O. ..G. .......,attorney in fact,full power and authority to do and perform all and every act and thing whatsoever requisite, necessary, and proper to be done in the exercise of any of the rights and powers herein granted,as fully to all intents and purposes as ..........M.. SL.Jc,"C,,;:Z .... ;....J.C)'-J L t................... might or could do if personally present,with full power of delegation, substitution, or revocation,hereby ratifying and confirming all that ..........4.......Jz-4K.r...............................attorney in fact,or his substitute or substitutes, shall lawfully do or cause io be done by virtue of this power of attorney and the rights and powers herein granted. 3.This instrument is to be construed and interpreted as a general power of attorney. The enumeration of specific items, acts, rights or power herein does not limit or restrict, and is not to be construed or interpreted as limiting or restricting the general powers herein granted to my attorney in fact. 4. By executing this document I further intend to revoke all previous general power of attorney appointments executed by me or on my behalf. This document is only a general form which may be proper for use in simple transactions and in noway acts,or is intended to ad,as a substitute for the advice of an attorney.The printer does not make any warranty,either express or implied,as to the legal validity of any provision or the suitability of these form in any specific transaction. Cowdery's Form No.1022-POWER OF ATTORNEY-General(Revised 3/92) t I have personally executed this document on ...............-��.`..�i� �l..,l.. ........... ./.............................. ..,19.. . . at...��'/ !,1�Y ............................................. .California. ... . � . . .......... .. .. .. .... ... ... .................................... (Signature Statement of Witness: I declare under the penalty of perjury under the laws of California that the person who signed or acknowledged this document is personally known to me (or provided to me on the basis of convincing evidence) to be the principal, that the principal signed or acknowledged this power of attorney in my presence, and that the principal appears to be of sound mind and under no duress,fraud,or undue influence. 1. Signature Print Name Date / Residential Address 2. Signature Print Name —. «r it t L^_ f T Date S c/'�y 3 Residential Address I LZA I v 471.1 X I 46 1 P /0� �� C/'I/ Notary Public: STATE OF CALIFO� Gam- . COUNTYOF.......................::�....................................................._ On this.....?.7...``.. . ...... da of.........�....... .......... in the year of 19..�c 3., Y before me,the undersigned,a Notary Publ c n and for said State,personally appeared.......:................................................................... .............personally known to me(or proved to me on the basis of satisfactoryevidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their FQ70AVID authorized capacity(ies), and that by his/her/their signatures) on-the :BACJIkAC instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. IA my °� SI Witness and and official eal. ......... ........................... ...... ... Notary Public This document is only a general form which maybe proper forum in simple transactions and in no way acts•Otis intended to act•ase substitute for the advice dam anomey.The printer does not make any warranty either express or imp4ed.as to the legal validity of any provision Of the suitability,of these forms in any specific transaction. .� Cowdery's Form No.1022•POWER OF ATTORNEY-General(Revised"2) a o FU to t a --_j pv uj a o Z WA .� CLAIM i_ z (QCT 151993 % BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA l CCii 114PI COUNSEL Claim Against the County, or District governed by) i%BOARD.ACTI[ONZ,CnZ' the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT NOVEMBER 9, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1500 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: McCOSKER LAND AND CATTLE COMPANY INC. ATTORNEY: Date received ADDRESS: P.O. Box 87 BY DELIVERY TO CLERK ON October 12, 1993 (via Risk Mgmt. ) Canyon, CA 94516 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. p g DATED: October 15. 1993 BgIL Deputy OR, Cler II. FROM: County Counsel TO: , Clerk of the Board of Supervisors (1/This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: Z�� 19 O BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (./f This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By ( . Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: BY: PHIL BATCHELOR by � ,�,� Deputy Clerk CC: County Counsel County Administrator Clair.: to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claius relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day. after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp G� S awl j RECE ED Against the County of Contra Costa ) OCT 12 1993 or ) �is P-� CLERK sol�RL OF supERViSq S District) -_ CONTR CCQSTA CO, Fill in name ) z The undersigned claimant hereby makes clai ainst the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) __ da- — 3. Hnw did the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? r (ove^) wnat are the n -mes of county or district officers, servants or employees causing the damage or injury? ( 5. What damage or injuries do you claim resulted? (Give full extent of injuries or d es claimed. Attach two estimates for auto damage. /11~d 6" GHQ 0r +-J eln RISo ee, �cr e— La ui ayes 7roY4 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) i N�----_------- $, NaTos a»l ?r dd --ses of wit«esses, doctor3 anua hospitals.s. �i5:�171 -N----------------------N----__ _N__N______M______-----N-_N_______N----- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some erson on his behalf." Name and Address of Attorney p �rv.b�nc Claimant's Signature) 4C 2 - Address Telephone No. Telephone No.e�61 NOTICE Section 72 of the Penal Code provides: - "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. L L? G U CLAIM � � �' OCT 51993 } J�' g BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA I COUNTY COUNSEL 4011nTJ1, Z CALIF Claim Against the County, or District governed by) GTh-14 =a the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT NOVEMBER 9, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $800,000-00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: SALOMON, Gerald L. ATTORNEY: Maurice Moyal , Esq. 1899 Clayton Rd. , Suite 100 Date received ADDRESS: Concord, CA 94520 BY DELIVERY TO CLERK ON October 14, 1993 hand delivered BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 15, 1993 Eqll Deputy OR, Clerk I1. FROM: County Counsel TO: Clerk of the Board of sors (vl� This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late'and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �e, �u �� l��d BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (� This Claim is rejected in full, ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. /� n Dated c ��r. PHIL BATCHELOR, Clerk, By. e Q l�th,t4,CDeputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately, *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. o Dated: 1'?93_ BY: PHIL BATCHELOR by fid,_ „ Deputy Clerk CC: County Counsel County Administrator GERALD L. SALOMON, CLAIM FOR PERSONAL INJURIES V. [GOVT CODE SECTION 910, ET SEQ] CONTRA COSTA COUNTY, RIVERVIEW FIRE PROTECTION DISTRICT, ALLEN LITTLE, WEB BEADLE, AND DOES 1-20, Defendants. / TO THE CONTRA COSTA BOARD OF SUPERVISORS 651 Pine Street, Martinez, CA 94553 . The Law Office of Maurice Moyal, represents Gerald L. Salomon, who was wrongfully terminated without cause effective 10/5/93 by Riverview Fire Protection District Chief Allen Little. Claim is made against the Riverview Fire Protection District and Contra Costa County for $800, 000. 00, representing future lost wages by Captain Salomon. We presently filed an appeal pursuant to present grievance procedures, but wish to make this claim at this time to preserve our rights pursuant to California Codes. Jurisdiction over the claim will in Superior Court. All communication with regard to this claim should be sent to claimant's attorney Maurice Moyal, Esq. , 1899 Clayton Road, Suite 100, Concord, California 94520. DATED: /Q ERALD L. SALOMON RECEIVED OGT 14 FACS CLERK 8OARD OF SUPERVISORS CONTRA COSTA CO. HAND DELIVERED 0 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA November 9 , 1993 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $6,000 .00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: SNIDER, Dana Edward ATTORNEY: Date received ADDRESS: 3258 Driftwood Drive BY DELIVERY TO CLERK ON October 15 . 1993 Lafayette, CA 94549 BY MAIL POSTMARKED: Hand Delivered via:Risk Mmt . I. FROM: Clerk of the Board of Supervisors TO:',, County Counsel'. Attached is a copy of the above-noted claim. �� Clerk IL BATCHELOR, CleQ, n DATED: October 20. 1993 : Deputy ycl� , o� o�Xxa�J II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ✓) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: N� � Z ? ` 9 BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ✓f This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:`j��,,,,_� PHIL BATCHELOR, Clerk, By a� ��., Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated`:"Tp� BY: PHIL BATCHELOR by q� ��_ I Q ) Deputy Clerk CC: County Counsel County Administrator �I Clair.: to: BOARD OF SUPERVISORS OF CONTRA COSTA omm INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal, Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp J IC( Qlwiyt�Sh ter HAND DELIVEREDV�o:: (Q Both.mr*- RECEIVED ) Against the County of Contra Costa ) OCT 1510 or ) , District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim ainst the County of Contra Costa or the above-named District in the sum of $ oao — and in support of this claim represents as follows: rN_rrr__r_Nr__ rNMr__w- N 1. When did the damage or injury occur? (Give exact date and hour) �'l�� 2. Where did the damage or injury occur? (Include city and county) _---_--_--_r-- 3. How did the damage or injury occur? (Give full details; use extra paper if required) e tfe fol. c.P ofFic:L, s- YC��iC�e S /2"CA 41 j del, .�Qiv►^ c� ��-� �o y' �- fi a cGr e /r,� 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? -� o1;,seAve de A c c..4le eihd Fa,,/e-w A c� �C-t'?° w Lo n�-e �-ve tri;e -F ��+-211. (over) �. wnat are the naves of county or district officers, servants or employees causing the dar^.age or injury? e At a� /e r,,e e M,2.-a les 1J n � ----- ------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give Hall extent of injuries or damages claimed. Attach two estimates for auto damage. C e-r r c� / /),e c,k" S r(z i n --u - s to a n wl — —MM--M 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) LQC,4.0d a,,R Ozec.(.cCa—,t b ,'115 a—,a �z- �.,��'u a5 F� dos f -�r`ru 3 h o�.r s p,�Gt• �.n/o."„/ a.-.c.c C�.S/] -o- -N------------N-----------N---- NMS ---I --- �MNM--J NN---�• 8. Names and addresses of witnesses, doctors and hospitals. ar aowc-,n cr>, o ell -0 9 ------------------------------------------ -------�.N------------------ 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 412 Thr } `g' , L— Ycisail r v e4 Wa c�+a e✓ hi</S Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney a-Li6L Claimant's Signature Address Telephone No. Telephone No. * * * * * * * * * * * * * * ,eve - NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for Payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. ,t r OF CALIFORNIA TRAFFIC COLLISION REPORT • - • PAGE /OF SPEGAL CONORIOlN aN HIT A RUI CRr JUOICIAL DISTRICT LOCAL REPORT NUMBER 1)u-r FELONY �— Em,:�ZG�/J4 HIT iRUN eouNrr i RtPORTwooRRNCT BUT 1 ro OLLMION OCCURRED ON MO. DAY Vw TIY6(9100) MGC[ 'OFFFICER L 0. /©5 9. d /06 MI NPORMATKlN DAVOP WEEK TOW AWAY PHOTOGRAPHS BY: WTFS OND u FEET/MILE! OF _ JO ElAT wIERsECriom m" l / - - BTAT[HM REL. OR: FEET/M/!Es N OFMT ( (�� f �.� - ❑Yti �p ®NONE PARTY DRIVERS LICENSE NUMBER STATE CLASS I SAFETY I? T MAKE/MODEL/COLOR D49 NMIEER STATE - G - S ?zD. 112 .W H. . . E7.0�92,z3 DR��IVVEpER NAME(FIRST.MIDDLE.LAR) PEDES. STRUT ADDRESS OWNERS NAM[ N ❑SAME AS DVEIM - TRI AN ❑ 130 �=A PARKED CrrY/RATE I ZIP OWN[Ifi R[6s (asAM[AS DRIVER VEHICLE sK:V_ SEX6"Al. 6:0.. WEIGHT MMD. .EIPITH.DAYATE Tw RACE"DISPOSITONOFYEHICL1ONGROERSOP! �"�OFACER (�ORrv[R ❑OTHER O titL7ff t ` �/r'J (� [� OTHER HOMIPHONE SUSW[q►NONB I G_ y��R \ PRIOR MECHANICAL DEPICTS: Ar REFER TO NARAA77VE ❑ &to) 4 AJIJC�.�B O ( / CW U6t ONLY OtsdSBBvtHICLEDAMAOIS BHA DEw DAMAGEDAREA ._.., wSUR1U/C[CARRIER POLICY NUMBER VEHICLE TYPE El ❑NONE 13 MINOR MOD. CIMAJOR ❑TOTAL Da OF ON STREET OR HIGHWAY S WET PCP ICC❑ ' PARTY DISV[R•suc[NSsNwSER [ STATE CLAS[ SAFETY V[K VEAA MAKE/MODEL/COLOR LICENSE NUMBER STATE z 78 -ryT2 oto& .;A" Co ter. . cp DRIVER NAMB(FIRST.WOOLS.LAST) -- (� - PEDES• STREET ADDRESS OWNS"NAME �SAMS AS DRIVER -. TRIAIt ❑ �=Tn or PARKED CIT//STATE I MP OWNS"ADOR[M (98AME RI AS DVER VEHICLE �( o Slcr. s" NNRLily HEIGHT WEIGHT ,Mo BIRTHDAYS.. YEA RACE DISPOSITION Of VEHICLE ON ORO[RE OF* FACER f"KR DOTHER eusT IT ❑ = l its A L4-75-75 OTHER HOME PHONE (� iUNltflf 15NONE PN011 YECNAHICAL OERCTB: NONS APPMEIRO REFER TO NARRATR/E❑ ❑ (.5 /A �8-f- 90©4 (4161 894-440 0 CN/USt ONLY Dt1CRIBS rEISCLt DAMAGE i1U10[w DAMAGED AREA wsURAME CARAI[R POLICY NUMBER VVNICLS 1rn - ❑IaB6 ❑(W1MI ❑MwoR .,�'8 i _3 Q ❑UM MAJOR ]TOTAL . TI OFL ON. tT OR HKLMVAY `r s p 13 PU , YL 123 Crap PARTY DRIVER'S UCENSE NUMBER STATE CLASS SA.Tf V[K YEAR MAKE MOOILL/COLOR LICIIINGSNUMBKA RATE 3 DRIVER NAME(AMT.MOMS.LAR) .. .. .- ►EOES RREETAODREss OWNS"MAYS SAME AS DNVER . PARKED CITY I STATE/D► OWNS"ADDRESS ❑SAME AS ONVIR VEWCIt Ncr. ux HAIR i HEIONT wamer M0. of moAra. YEAR RACE OISPOUTWN OF VUBCLE am OR0[R6 OR .nG mafi ❑DNvER ❑OTHAR COSTL� OTHER HOME PHONE BUSINESS PHONE PISOR MECHANICAL DIPECM NOW APPARMT C] RERR To NARMTIVE❑ ❑ ( CNP USB ONLY ppCN/t vEHICLE DAMAGE SHAD[IN DAMAGED ARIA INSURANCE CARRIER POLICY NUMBER V09CL E TV" I C 1— ONONE 0Mw01R i ❑UOQ. ❑MAJON TOTAL OIR.O/ 1.14STRASTORMI.NWAY 16111111 PCF ow VEL LIMIT PUC D PREPARER- NAM DISPATCH NOTIFIED lRamwwaffs NAM[ DATE REVIEWED AYES ❑No C3 NIA CAPUS PAGE I pry TSR 1 OPI 043 d y j /��(�y88 48661 TRAFFIC COLLISION CODING ` C., /° �. a DATE OF C6ItL1SION TOE(24M) NGIC NUMtFII Mo. AOf -ll�yl.D tai NUYYEII .r. C. r.. .0 /DAr rrll lK�i OWNER'S NAME/ADDN[SS PROPERTY DAMAGE DESCRIPTION Of DAYAOi SEATING POSITION SAFETY EQUIPMENT EJECTED FROM V OCCUPANTS L-AIR SAO DEPLOYED M 1 C BICYCLE.uFI ucr A-NONE IN VEHICLE- .- M-AIR BAG NOT DEPLOYED 0-NOT EJECTED B-UNKNOWN N-OTHER DRIVER /-FULLY EJECTED- 4 C-LAP BELT USED P-NOT REQUIRED V-NO 2-PARTIALLY EJECTED 1-DRIVER 0:LAP BELT NOT USED w-YES 3-UNKNOWN 1 2 3 ESHOULDER HARNESS USED - V 2 TO 6-PASSENGERS CHILD RESTRAINT PASSENGER 4 5 6 T-STATION WAGON REAR F-SHOULDER HARNESS NOT USED X-NO 8-REAR OCC.TRK.OR VAN G-LAP/SHOULDER HARNESS USED 0-IN VEHICLE USED Y-YES 9-POSITION UNKNOWN H-LAP/SHOULDER HARNESS NOT USED R•IN VEHICLE NOT USED - --- - 7 0-OTHER J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-MORE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR MOVEMENT PRECEDING UST NUMBER.(s)OF PARTY AT FAULT TRAFFIC CONTROL DEVICES 1 2 3 _TYPE OF VEHICLE 1 2131 COLLISION y x lAvc SECTION VIOLATED: CILTI ACONTROLS FUNCTIONING APASSENGER CAR I STATION WAGON ASTOPPED 2 O CB CONTROLS NOT FUNCTIONING• B PASSENGER CAR W/TRAILER B PROCEEDING STRAIGHT >t B OTHER IMPROPER DRIVING•: CONTROLS OBSCURED C MOTORCYCLE/SCOOTER RAN OFF ROAD DNO CONTROLS PRESENT/FACTOR• DPICKUP OR PANEL TRUCK D MAKING RIGHT TURN COTHER THAN DRIVER• TYPE OF COLLISION E PICKUP/PANEL TRUCK w/TRAILER MAKING LEFT TURN -- -- D UNKNOWN• HEAD-ON F TRUCK OR TRUCK TRACTOR MAKING U TURN r E LL B SIDESWIPE TRUCK/TRUCK TRACTOR W1 TRLR BACKING - REAR END SCHOOL BUS SLOWUIG/STOPPING WEATHER( MARK/TO 21TEMS) D BROADSIDE . I OTHER BUS 1 PASSING OTHIETVEHICLE ACLEAR HT OBJECT EMERGENCY VEHICLE J CHANGING LANES' B CLOUDY F OVERTURNED KHIGHWAY CONST.EQUIPMENT 1(PARKING MANEUVER RAINING VEHICLE I PEDESTRIAN L BIcYCLE ENTERING TRAFFIC SNOWING OTHER•: OTHER VEHICLE OTHER UNSAFE TURNING E FOG/VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH M KOESTRIAN XING INTO OPPOSING LANE F OTHER•: JE NON.COLLISION MOPED PARKED IG WIND PEDESTRIAN MERGING LIGHTING OTHER MOTOR VEHICLE - ._. . . - TRAVELING WRONG WAY. . A DAYLIGHT MOTOR VEHICLE ON OTHER ROADWAY OTHER ASSOCIATED FACTOR(S) OTHER•: B DUSK-DAWN PARKED MOTOR VEHICLE 1 Z 3 (MARK 1 TO2ITEMS) DARK-STREETLIGHTS TRAIN Ave v'OLAT N: �p vn D DARK-NO STREET LIGHTS BICYCLE ND QNo DARK.STREET LIGHTS NOT ANIMAL: BvesceTla+vpunoN: �}Tp '- - - FUNCTIONING• Ova ROADWAY SURFACE 0NO 308METY-DAM _ PHYSICAL A DRY FIXED OBJECT: va Ova 1 Z 3 (MARK TO 21 ITers) B WETOTHER OBJECT: 13Np HAD NOT BEEN ORIMUNG SNOWY-ICY D CE D SLIPPERY(MUDDY,OILY.ETC.) E VISION OBSCUREMENT: B HBO-UNDER DR IINFLUENCE TION•: HBO-NOT UNDER LUU ENCE ROADWAY CONDITION(S) INATTENI ID HBO--IMPAIRMENT UNKNOWN PEDESTRIANS INVOLVED STOP i GO TRAFFIC IE UNDER DRUG INFLUENCE (MARK I TO 2 ITEMS) H ENTERING/LEAVING RAMP A NO PEDESTRIAN INVOLVEDIMPAIRMENT-PHrSICAL PREVIOUS COIJJSION HOLES.,DEEP RUT• CROSSING IN CROSSWALK IMPAIRMENT NOT KNOWN B LOOSE MATERIAL ON ROADWAY• B AT INTERSECTION UNFAMILIAR WITH ROAD NOT APPLICABLE C OBSTRUCTION ON ROADWAY• K DEFECTIVE VEK EQUIP.. pRp, CROSSING IN CROSSWALK-NOT Qrp 1 SLEEPY/FA71GUED D CONSTRUCTION-REPAIR ZONE AT INTERSECTION ONo SPECIAL INFORMATION E REDUCED ROADWAY WIDTH ID CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE I IAHAzmwousmATEmL FLOODED JE IN ROAD-INCLUDES SHOULDER OTHER•: OTHER•: NOT INROAD NONE APPARENT M NO UNUSUAL CONDITIONS APPROACHING/LEAVING SCHOOL BUS RUNAWAY VEHICLE SKE C H HIPp Us 19C CHP _ %IIT. RAM RC: 4T..._.. O: "VIM, ..r CHP SSS PAGE 21—Row i-")OPI-2 ST?.TE GF A'�.:FORN�A ` FA:;TUAL DIAGRAM + - 3 • -e OF ,011e Sion nE 12�0p1 �NCIC NUMBER '7F ER 1.0. NUMBER 7o<n cS/� ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE _ y vt-1 -vb I .Tt O IT. Sl�uc sl oEw��a< 1 r(D(D ,E 40 37� owwM wr 1.0.NYM�fw MO. OAr rw. w<Vlu wtw'f NwMt YO. OAr rw. CHP 555—Page 4 18ev 11.85) OPI 042 �I � r • / r rA ■ : ■Mir., ■ .. • li Ell r -► • _ . r Lr' R �Wff"Imp ` � 1 �L . , it ' G i � r • ,.' L i/ E A kl.W AW IMF /� r �a • i.a i I I t� i2roMwWU r _,?= G., DATE OF INCIDENVOCCURRENCE NUMBER OFFICER I.D.NUMBER J i ')r ONE TYPE SUPPLEMENTAL rX-APPOCABLE) Y, FatalNarrative D EIA update E 0 Hit and ruinqupdate. Supplemental .� Other REPORTING DISTRICTIBEAT Wjj f • ■ YesNo �A Me W,1111111111111111 lw'� MA /�../ • . /! • CAJWI . it 1G !sr' L" _I L• • rim! WOMAN L � r► // t.lC • • C �.� Cs Imo•' .t G .. ie L � /l its � iL ! r • ��G r i .•.r / • � Ii • :.�► s.��: amu►: . � � � -ten: t • . � Lei �.. l_i tai. ._ �� i..• i. �r�[1 O..t .�.,' ._ .� .. NCIC-NUMBER ✓ .� r_r ■'X'ONE TYPE SUPPLEMENTAL rrAPPUCABLE) ✓ Fatal XLNarrative 1� XCollision report El BA update E ED Hit and run update emen LQ Other: 00ther: CITYXMUNTY/JUDICIAL LOCATION/SUaJECT STATE H04WAY RELATED ■ Yes . /moi! / ! V �� ri. • v ..�A.. AF ti moi. f..�' �r�� i► '�GWmi, fr / MMIC: AWOULt� AMU low WAL WIN FAIR, C 0 F P-a F WAR I K�Y"- ,on 3 �r huC �_Gi✓ tr � � i/�� ♦ t� � � t�r! � aI V qW - .. - -"� Medical Payments Proof of Claim SUFFIX m CaGlomia Slate Aulortwttile Association SUFF I X Inter-Insurance Bureau SNIDER, DANA, E I. Fillin all spaces below 09—E05833-3 05-03-93 2. Attach the original of each bill listed 3. Attending doctor must complete report on revtasc side. Additional 02 MP doctors may report on form which will be supplied upon request SNI DER, DANA 4. Proof of claim must be dated and signed by the injured person L AF 3Q132.. Q 5-04-93 COVERAGE IS LI1vffIL•D TO NECESSARY AND REASONABLE EXPENSES INCURRED wrhEN ONE YEAR FROM TILE DATE OF LOSS. Plewa rete to the policy section regarding Esperssea for Medical Services and the declarations page for a complete description crow eoverago,tights,obligations,and a ddinhion of u-nns as well as CSAA-tiffs rights relating to medical payments, uyou have any questions regarding any aspect of this coverage or of the claim promdrn•e,plcs aak your claim rrprorntativc for claril;cation. If your clainr rcprarntative is unavailable,ask Cora supervisor. HARE or aiNRED PERSON DATE OF BIRTH ADDRESS vl I CK=-MAT10N SOCIAL SECURM NUMUER 17 WILE DIAMES SL=ASHEDal E OF EMPL.OYMOM IES,F Y1S 1NRAlEO s=ECRK rTJ WORKERS COMPE14SATION SENEFITM ❑YES "No ' ❑YES ❑NO D©YOU SIGN AN ASS`II'GNI.CENT OF BENEFITS ON BEHALF OF ANY HEALTH CARE IF INJURED PERSON IS A MINOR.GIVE NAJ(MS OF PARENTS pROVIDERT IF YET.LIST PROYMER'SNAME ❑YES ❑NO LIST BILLS BEIAW HILLS NAI 7 YES NO AZ,tOtJh- h/ 0), Y,��TOTALq- Ar1E TIM Bn t t LISTc.D ABOVE T 1E LAST BILLS TO BE StJBMrrI ED7 ❑YES For your protection California Law requires the following to appear,on this form: /y ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR TIIE PAY-NfENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. (California Insurance Code Scction 1871.2) Tl A undersigned hereby eenifics tlul the above items in this Proof of Claim together wid,the attached itemized bills covering such items,ase true and correct and were irx cd as a result of an aecidcnL Signature of Signed at injurcd person (CITY) Or parent Or guardian Of a minor DA 1 WITNESS ADDRESS OF W iTNESs l HEALTH INSURANCE CLAIM FORM FORM APPROVED (CHECK APPLICABLE PROGRAM BLOCK BELOW) OMB NO.0938-0009 MEDICARE MEDICAID CHAMPUS CHAMPVA FECA BLACK LUNG ,OTHER (MEDICARE NO.) (MEDICAID NO.) (SPONSOR'S SSN) (VA FILE NO.) (SSN) E,(CERTIFICATE SSN) Li - PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME(LAST NAME,FIRST NAME,MIDDLE INITIAL) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME(LAST NAME,FIRST NAME,MIDDLE INITIAL) 4.PATIENT'S ADDRESS(STREET,CITY,STATE,ZIP CODE) 5.PATIENT'S SEX 6.INSURED'S I.D.NO.(FOR PROGRAM CHECKED ABOVE,INCLUDE 77 11 ALL LETTERS) 3238 8 DR 1!'TIV:00D DMALE I Y 1✓ �FEMALE566789248 LAFAYE'l-VE CA 945-49 7.PATIENT'S RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO.(OR GROUP NAME OR FECA CLAIM NO.) SELFSPOUSE CHILD OTHER "� r(� F'^� INSURED IS EMPLOYED AND COVERED BY EMPLOYER TELEPHONE NO. ; l (j } 7? 41-« A 3 0 0 [:] � �HEALTH PLAN 9.OTHER HEALTH INSURANCE COVERAGE(ENTER NAME OF POLICY- 10.WAS CONDITION RELATED TO: 11.INSURED'S ADDRESS(STREET,CITY,STATE,ZIP CODE) HOLDER AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE NUMBER) 3258 -T r•�r1 (�r '� A.PATIENT'S EMPLOYMENT _NONE REPORTED YES❑ D&IO LAFI:! YE' TE CA '94 49 TELEPHONE NO. ( ��. 0 ) 7 L�? 11.a. CHAMPUS SPONSOR'S B.ACCIDENT AUTO OTHER I ACTIVE DECEASED BRANCH OF SERVICE STATUS DUTY Li I=RETIRED 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE(READ BACK BEFORE SIGNING) 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM.I ALSO REQUEST PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. PAYMENT OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNED C T 7\j,_'T?'''r !j Y s.' ( r.'�' DATE I SIGNED(INSURED OR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION 14.DATE OF:} ILLNESS(FIRST SYMPTOM)OR INJURY 115.DATE FIRST CONSULTED YOU FOR THIS 16.IF PATIENT HAS HAD SAME OR SIMILAR 16.a.IF EMERGENCY (ACCIDENT)OR PREGNANCY(LMP) CONDITION ILLNESS OR INJURY,GIVE DATES CHECK HERE 17.DATE PATIENT ABLE TO 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK FROM THROUGH FROM THROUGH 19.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE(e.g.PUBLIC HEALTH AGENCY) 20.FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION DATES ADMITTED I DISCHARGED 21.NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED(IFOTHER THAN HOME OR OFFICE) 22.WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? YES r=_1l.NO CHARGES: 23.A.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY,RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE B. NUMBERS 1,2.3.ETC.OR DX CODE 1. 84-7 . 0 ,l ( . 0 SEPPAfN/S LRZ'iLd _'ERV.L_'ciL NECK EPSDT YES Q El NO 2' FAMILY PLANNING YES a f7 NO 3. PROR--'----------'-'------ I 4. AUTHORIZATION NO. 24. g" C.FULLY DESCRIBE PROCEDURES,MEDICAL SERVICES OR SUPPLIES F. H.LEAVE BLANK A. PLACE FURNISHED FOR EACH_DATE GIVEN _ _ __ D. DAYS DATE OF SERVICE OF PROCEDURE CODE DIAGNOSIS E. OR G.- FROM TO SERVICE (IDENTIFY ) (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS T.O.S. I 07, 06/93 ? (-t I I 1 1 I 1 I I I 25.SIGNATURE OF PHYSICIAN OR SUPPLIER(INCLUDING DEGREES(S)OR 26.ACCEPT ASSIGNMENT(GOVERNMENT 27.TOTAL CHARGE 1 28,AMOUNT PAID 29.BALANCE DUE CREDENTIALS)(7 CERTIFY THAT THE STATEMENTS ON THE REVERSE CLAIMS ONLY)(SEE BACK) I APPLY TO THIS BILL AND ARE MADE A PART THEREOF) I , YES O [3-NO 31. PHYSICIAN'S,SUPPLIER'S,AND/OR GROUP NAME,ADDRESS,ZIP CODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. CA 1 1 N- - - ,3(if.:N . ._.-ti L L.?L' (J i-i_C� !'1.. :ifS_i 18 <�r Li I::�C,i1 :-i'i� .. -._ DATE S C0 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.O.NO. - 6 ' I.D.NO. REMARKS F SERVICE AND TYPE OF SERVICE IT.O.S.)CODES ON THE BACK APPROVED BY AMA COUNCIL Form HCFA-1500 (C-1) (1-84) Form OWCP-1500 ON MEDICAL SERVICE 5-83 Form CHAMPUS-501 Form RRB-1500 r K • z m OO CD o i 0 �d `may � zxo P z w -r* H zxo ,P 00 tzj i. O 1 z w �M KN 00� z � .4-r --rw 0M Jar --rw m�iZs t7 cnyrn H. my:to d cnrn 1�ro z o 1✓ro0. C b z o F--A .P 1 >0 w oy%D lo 1 >0w Obi J V-+ro LZI ct y �-K0 m J 1-•to M ct y .—�C w m to'o m N ts]m w w w m tow ID N tz7 X J O\� m�-3 H C J 0�,- m H H ON trn O WH. W fD QN to O w H 10 G v, 1 t1i x P. 1 0 c.1 v+ 1 t� 000 U O 000 10- o In 3 x o ►-+ H lok< U1 Mx 0 1- H a J 00> loo az . J 00> 1r+ H mfr zz H 1.9� �� O>tOi w O > w O N w kO 0 O lTl cn t-4 H rn O 0 to to t01' v>z o wd� loi.� yz o koo Wva yN WCr1 N Ff,• N m r m Obt4i P 1 � 1 c 0 0 OD m boll till J J J J J J APPRQVED OMB 0938 000H PLEASE: 3o DO NOT Mati�aa "tn'. ; STAPLE P. O. BOX-705.2 IN THIS: " " . . .:u,az».,:. mrnr+rtttts♦3:ara •�P.*ssMn> 2fV,)bfi l: San Frnncf_s'co"- AREA yrs.,�9rt is is HEALTH 1NSURANCE.CU M.FORM - PICA 1. MEDICARE MEDICAID., _ "-;CHAMPUS _ CHAMPVA" GROUP FECA OTHER Ia.INSURED'S I.D.NUMBER`;;; :;::• (FOR PROGRAM IN ITEM 1; HEALTH PLAN BLK LUNG 5 ' ' Deb 7.8-9248; -, ) (Medicare#) (Medicaid"#) ' (Sparrss SSM`: " (VA Fie/) (SSN or ID) (SSN) El (ID) 2.PATIkNT'S NAME(Last Name,Fust7f mI" 3.PATIENTS BIRTH DATE SEX 4.INSURED'S NAME(Last Name,Fast Name,Middle YW,at) Snider, :Dana 's,:i,,,ip 9tu1Fif1: tJ MM :�..� 'GJ N'4' 3n.ider; 5.PATIENTS ADDRESS(No,,SU M4 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS fVa Street}- _ 3255',A �+TrOdryf��-�.�+ ,I. . X. 3253fwoad .Drive Set;❑"Sparse❑ Child❑ orae �. TE CITY STATE 8.PATIENT STATUS CITY STA LaferRtte CA _�fcYette Single Married❑ Other❑ ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE Employed Fun-Time Pan-Time '4 4 7 - ❑ Studer ❑ Student ❑ / 9.OTHER INSURED'S NAME(Last Name,Fust Name,Middle Initial) 10.IS PATIENTS CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER _ t� 900 a.OTHER 1NSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX MM' I DO YY YES ❑NO �' 1 1'• M[jF b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM,.,t!:DD.1: YY: tiv3i %r :,I•.`= O J( C^aVran'C.Or:p:,. . . . r1 i a f l F ❑YES ❑N c-EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME ❑YES ❑NO Y Ill c'tr6AC.13tan L'aiir d•INSURANCE PLAN NAME OR PROGRAM NAME: 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? - _. ._. ❑YES ❑'NO.X. K yea,return to and complete dem 9 a d. READ READ BACK OF.FORN BEFORE.COMPLETING bSIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier:cr to process this claim-.Il�yyee of y rerq(r(¢nt r fits either to myself or to the Parry wild axeptsUassiment 9 11 J services described r below. `J1VIYf� t^� .r...,- . 1.40TURE 4N tr.VE DATE SIGNED SIGNED " • ' 14.DATE OF CURRENT:'- ILLNESS(Fkw symptom)OR' '` 15.1F PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DD I YY INJURY(AccideM)OR. GIVE FIRST DATE. MM .I DD I YY MM:a OD V I;.W!:;a MM::r;'DD.I YY ' PREGNANCY(LMP) ' FROM 1 I TO I 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION-DATES RELATED TO CURRENT SERVICES CALLANDERt. JOHN' M' 15 ,#A9'47 2 #A94702 MM , DD I YY ' TO MM-,I DD , YY FROM. 1 :!•1' 19.RESERVED FOR LOCAL USE .:.`.:"- 20.OUTSIDE LA0? "'""' E CHARGES" s31%rr; ?i G- I ..: ❑YES ❑NO.` - 21.DIAGNOSIS OR NATURE.OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION 2 .��:: CODE -ORIGINAL REF.NO:: < 23.PRIOR AUTHORIZATION NUMBER 24. A B C D E F, .. G.z H• I J K Fr DATE(S)OF SERVICET - Place Type PROCEDURES,SERVICES.OR SUPPLIES DIAGNOSIS � DAYS EPSD � RESERVED FCF� of of. (Expla n UogsL LCircumstances) CODE $CHARGES OR Family EMG COB LOCAL USE MM DL1 Y-4 4 MM93 DD W S CPT/HCPCS . MODIFIEq rJ U10IN Plan 1 '0 14 1n 7J .�. - t a i J 2 - - -- _ . . I 1. 1 0f, 18 .: 93971 -". 1 .;.-1-.:!. . - .�: 1 I 3 t11 r I I - I I 3 1 4 s � ' 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENTS ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29 AMOUNT PAID 30.BALANCE - Fcr govt.claims.sea ck) >4-3011921 ❑❑ X 1SIvI0.l = a vEs DNo $ 31.SIGNATURE OF PHYSICIAN OR SUPPLIER• 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S,SUPPLIER'S NG NAME,AD 3S,"ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(It other than home or office) 8 PHONE M B A R C A D E R O P H Y c,I C AL .THE k r (I certify that the statements on the reverse . apply to this till and are made a part thereof.);; r•:;• .:: - 4- U B A'TJ E R Y,r S't . r S U I T G _ BRIAN `3=:` BEAUDO'IN' OlOS2' SAN FRANCISCO. CA' 941?: •. ";" '' 05119/93 94_3011921' SIGNED DATE""r PIN# GRP# FORM (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE _ HCFA-1500 FORM OWCP- (12-90) 150 500 FORM nR;i PLEASE'' _ •c. - CSq.NT - :,.? '"7.^. `i1 ?ifi%i: ;�' z'}Ei�T'i�.r APPflQVED OMB 0938 DOCS 4: Db NOT '. Met rop'olitan . Lii �- STAPLE P. O. Box 7202 .� IN THIS:. f S3Sistri{r��.. . AREA San._ Francisco CAv. ;. _nPICA HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID,;Gi;j 3 CfAQMR)a jZ;bUi7'OH PVA!:: GROUP FECA OTHER ta.INSURED'S I.D-NUMBEA;rrirM-Ni:_.:t:(POR PRQGRI M W ITEM; HEALTH PLAN BILK LUNG (Medcare 0) (Melitcaid tJ - SSrV) (VA File )1 (SSN or/D) (SSN) (ID) J E 6- C-9 2 8 t t''`;:,d a, 2.PATIENTS NAME(Last Name.First Nam,Middla trYtial)_,l.- 3.PATIENTS BIRTH DATE SDC �if3r,4.INSURED'S NAME(Last Name,Fust Name,Middle Initia DO YY Snider, Dana :i• ;, .;;�: .. 051 2511 4o M F J r , Dena; 5.PATIENTS ADDRESS(N..StreeQ,I r a. � 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No,Street) 5258 Driftwood';:Drive i,l'' self® spa,ee� knee❑ otne.� 3255 Driftwood -0i^ive CITY STATE S.PATIENT STATUS CITY STATE Lafayette CA single E]. Maenad other F L a f a y e t t t . ,. .. ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE cr s ( rJ 2 p Q�►T:9 O 8 4 Employed❑ Full"Time Student E] Student 9 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENTS CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER ' 617 0 a.OTHER INSURED'S POLICY OR GROUP.NUMBER,;- , a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH. SEX: MM j Do,I YY �,r.:.•:_i -. YES NOM i.n. .. .. M E] F I I :f b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM , DD ,- YY.. >, F YES X U i I ; M C,hAVI^Oli COrco. ... -. c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME:OR PROGRAM NAME r YES 01110 Lit& d.INSURANCE PLAN NAME OR PROGRAM_N. 4:i tWI 1 Od.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? . ' .v. DYES' `a NO"''t=-H ym return to and complete item 9 a-a. READ BACK OF FORM BEFORE COMPLETING&SIGNING.THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I auftrae the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier icr to process this claim.I also request payment of goverrur ent benefits either to myself or to the parry Niro accepts assignment services described bebw-1;•_:,; ti..,:;`•. oLGNA.TUFE. ON:=E:ILE:;txh: �.: 05/.25/93. SIGNATURVON.. FblsE:,�:::' SIGNED _ i r. L DATE SIGNED 14.DATE OF CURRENT- ILLNESS(Fust symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DO I YY INJURY(Accident)OR•. GIVE FIRST DATE MM I DO I YY MM I DO' i.yY;_, , MM:r_'W,,f YY i PREGNANCY(LMP) I I FROM I 1 TO 1. -I 17.NAME OF REFERRING.PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES :,�.•:, .;11,i;_ :. MM , DO j YY MM l DD 'I YY CALL-ANDER .•tJOHN3tMC'D!4"''t"'4-7fl2-,r, „_4A94-702 FROM TO':. 19.RESERVED FOR LOCAL USE .:; ".;; :. " 20.OUTSIDE LAB7 """`"'""i' $CHARGES 3°sea=:�tt 1 7t x;12 n'ltrS .til 3^91 t :i:.. YES 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO REM 24E BY LINE) 22.MEDICAID RESUBMISSION v ys• CODE ORIGINAL REF-NO-ti; t ` 1. L- - 3. „. 23.PRIOR AUTHORIZATION NUMBER 24. A .. .. ^I1-; r,:,. _;:. ;B C. D E F G - H :• I JK From OF SERVICE ro iU ai:: Place _Type: PROCEDURES,SERVICES,OR SUPPLIES DAYS EPSD ,;•,,.. DIAGNOSIS RESERVED FOR -t; :-:of of• •---(Explain Unusual Circumstances) OR. Family MM a DO+ YY +MM' DD'1,"'YY C C MODIFIER CODE S CHARGES ae UNITS Plan" EMG COB LOCAL USE 1 Cr v` 2 3 2i ~' 97125 2 0� �r , : 971'10 1 5P .00 9�lIw 1 3d 00 0' `� ; :i, i ,r:r. r, +. •. 97120 3 J - •r, I 5 i 6 25.FEDERAL TAX I.D.NUMBER•;: •SSN FIN 26.PATIENTS ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29 AMOUNT PATO 30 BALANCE DUE t For govt.claims,see back) 9u-3011921 OX. �141SNIDD S a vEs 0 No s 220 001 $ I s _2?r. __ 31.SIGNATURE OF PHYSICIAN OR SUPPLIER,:::3Z: 32.:NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S,SUPMI9 Bbl IaG,I1BM,AIL2,DDRESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) pypJJ� (I cattily that the statements on the reyerse LIICAK�'ADER6'`PHYsI'CAL THERAPY I;1- . apply to this bill and are made a part thereof:) ' : ,, ::!>r.. 625 BATTERY `S T`:;''.,•$UITE 3B_` _RIAN ?. 6EAUD6INn'#010 27 SAN FRANCISCO, CA 94113 3 0119 21GRP# SIGNED., . . , (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 6/88),. PLEASE PRINT OR TYPE FORMkICFA-1500 (72-90( ' ` `' FORM OWCP-1500 FORM RRB >0 m O C V E1IIm2 Z o m N R C R Ar I Cl- m O O m M a p O t0 n J1 j£ .. C C") a U MW>W w a o U • T A v T t W ~ •- U U a U J J m• cpm O C v -;- 3 � Q w c ME U c ° Uf- F- aFa _ ^ ►- a n ViicMo�' ^ a�i1J ! v QCj ON QWCL Z y w a W2,m2; >. w c M m aY� �JOa� a C U y 2 t � da Ca0.iciuLr Q w a W Q v C70Q Z ¢ Q N z a p c ; O F m — m 3 w Q w m n:' ❑ n n CC w CL > C7 W Q 2 Jw -1QwOm = j C•fl` ,J ,v W = W -1 1J ' E o� WaL>Ln O L7 tN � 2 QLU z J N Z E ° Fd~ oF- o Z - C= U = � QCL � — w O Z I LL T m Z am0ouLU � � ❑ Q cmc 2i ❑ a ❑ `o Q IIa Lav v� - r - LL LL ` I - O O Q N O N V fD O Ln O N m � = v CL 9L Z ° w • N � j Q C � � \ ��1 U C m L ,� m a m W p W ro. m •C �, O_ O w o ' .� o ° o o M a ti F U O nr. Q O L o 3 w } .d I WU. n n in L7 Ln U y O OO O N N C) a) C C' tOD O I I Z _ _ N N n n n n n n00 LO n I J _ _ > n n n n n n n n n In n - .. CC m (n m m O) co m (n m m m C) I -_ ? z Lr) •, C_ C_ C C C ` J ° m O. y 0 0 Q 3 Q F Q LL' w L c Q Q y N Z z _ = -C ❑r -C O Y = > o m z m' m c c m a O a w O a w w w J m Y M w m m O !- ❑ 05=/10/95 14:54 V415 894 4796 CEMON TAI DEPT y- X1004/004 sm Glitoeaia St.Suis 715 San Fsandrm,Cskfoc 94118 �oHI+K 41S."Ill-i01l 361- �-1 a 0 �.,�. DX415.7S2-2UA ❑ramicluc V.DOST,Y.D. 01FHEHOM LA PjNLp- 0o1LLWl L.GRerm mm. Mommy-Fndry BM a -X00 p,m. ✓ O TAYLOR X.SMITH.ht D. m PHYSICAL THERAPY REFERRAL o;N 1 MVICIMED MD. To .11 Ccs '`rte PHONE{4(S) �- IMWCE PA7MVT PHONE{ ) ftCALMONS ftwu a DIIRAnON DATE • { ,.. -� ~- Madkal Payments Proof of Claim Is ykJF F z x ® Catilor a State Automobile Association Inter-Insurance Bureau SN I DER, DANA, E 1. Fill inall spaces below 09—EO5833-3 05-03-7 2. Attach the original of each bill listed 3. Attending doctor must complete report on reverse side. Additional 02 MP doctors may report on form which will be supplied upon request SNI DER, DANA 4. Proof of claim must be dated and signed by the injured person, _LAF __, 30132 .__05--0.4-93- COVERAGE 05--0.4-93.COVERAGE IS LDv -D TO NECESSARY AND REASONADLE EXPENSES INCURRED Wdim ONE YEAR FROM TTIE DATE OF LO Please rcfcr to the policy aeclion regarding Exr in for Medical Services and the declarations page for a complete description of the coverages,rights,obligations,and a definition of terms as well As CSAA.IIB's rights relating to medical payments, lfyou have any questions regarding any upeet of this coverage or of the claim procedure•F ask your claim r presrntaliva for clarification. If your claim representative is unavailable,ask for a supervisor. NAME Of 9HJU110 PERSON DATE OF DIRn ADDRESS )k-�:>CL c,\�. S 1 , r S z S-�f� 3 S Dtit f V7 -d� Q(� 1.c�>lay L'-f Q OCCi,PATIOH SOCIAL SECURITY NUMBER WTILE RUURIES SUSTAINED INF EMPLOWENT7 IF YES,15 INJURED SUDJECTTO WORKERS COMPENSATION DENEFRS7 O YES COU NO O YES • ONO DM YOU SIGN AN ASSSIGHI tMNT OF BENEFITS ON BEHALF OF ANY HEALTH CARE IF SNARED PERSON IS A 1.d1NOR.GIVE NAAdES OF PARENTS PROVMER7 IF YES.LIST PROVIDERS NAME Oyu ONO LIST BILLS BELOW NAI 7 YES NO AMC o P94X — :5 tw bat 00 1 TOTAL.2?6 ARE THE BILLS LISTED ABOVE 71 IE LAST BILLS TO BE SUBh=D? ❑YES �J70 For your protection California Law requires the following to appear,on this form: !v ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR TI IE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. (California Insurance Code Section 1871.2) The undmlgned hereby ccrtifia that the above items in this Proof of Claim together with the attached itemized bills covering such items,are true and correct and were incurred u a result of an accident. !� n Signature of /A�,�f�A,�, gncd at injured person !�t/V w �_4jl (CITY) (STAT Or parent guardian o a f / )l�^ minor �(/ C- DA.rz�/ 6 ,2-0,93 W TNESS ADDRESS OF wltt•rESS FIST In". HEALTH INSURANCE CLAIM FORM FORM APPROVED (CHECK APPLICABLE PROGRAM BLOCK BELOW) OMB NO.0938-0008 MEDICARE LllMEDICAID CHAMPUS CHAMPVAL�j FECA BLACK LUNG �� OTHER (MEDICARE NO.) (MEDICAID NO.) LJ(SPONSOR'S SSN) L-i(VA FILE NO.) (SSN) (CERTIFICATE SSN) PATIENT.AND-INSURED(SUBSCRIBER)INFORMATION 1.PATIENT'1S`NAME(LAST NAME,FIRST NAME,MIDDLE INITIAL) 2,PATIENT'S DATE OF BIRTH 3.INSURED'S NAME C NAME(LAST NAME,FIRST NAME,MIDDLE INITIAL) _ITii'llA =. `T J~ 1L *FLtN" E- 4.PATIENT'S ADDRESS(STREET,CITY,STATE,ZIP CODE) 5.PATIENT'S SEX 6.INSURED'S I.D.NO.(FOR PROGRAM CHECKED ABOVE,INCLUDE ALL LETTERS) -- MALE ��+ D FEMALE • "�1,tj <�•-`•T'(1;^:4. 7.PATIENT'S RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO.(OR GROUP NAME OR FECA CLAIM NO.) SELF SPOUSE CHILD OTHER ��-�?'7,j INSUE TELEPHONE NO. -..' El El 11 El H ALRTH PLSi4NMPLOYED AND COVERED BY EMPLOYER 9.OTHER HEALTH INSURANCE COVERAGE(ENTER NAME OF POLICY- 10.WAS CONDITION RELATED TO: 11.INSURED'S ADDRESS(STREET,CITY,STATE,ZIP CODE) HOLDER AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL - _r z F-T1�1>:�0D D ASSISTANCE NUMBER) _ I 1 -} _ F .+ -- -. ..-- -Ai.PATIENT'S EMPLOYMENT - `_ - - - vesF NO !AFPIYETTC CA 94514'=; TELEPHONE NO. 11.a. CHAMPUS SPONSOR'S B.ACCIDENT 1 ACTIVE DECEASED BRANCH OF SERVICE AUTO OTHER STATUSI DUTY :[::]RETIRED 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE(READ BACK BEFORE SIGNING) 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM.I ALSO REQUEST PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. PAYMENT OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. <<T fa;':! 1'Ii'!_y'.-tE= '1!'! r T i._�= SIGNED DATE SIGNED(INSURED OR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION - - 14.DATE OF: ILLNESS(FIRST SYMPTOM OR INJURY 15.DATE FIRST CONSULTED YOU FOR THIS 16.IF PATIENT HAS HAD SAME OR SIMILAR 16.a.IF EMERGENCY (ACCIDENT)OR PREGNANCY( LMP) CONDITION ILLNESS OR INJURY,GIVE DATES CHECK HERE El 17,DATE PATIENT ABLE TO 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK FROM THROUGH FROM THROUGH 19.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE(e.g.PUBLIC HEALTH AGENCY) 20.FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION DATES ADMITTED I DISCHARGED 21.NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED(IF OTHER THAN HOME OR OFFICE) 22.WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? YES 00 NO CHARGES: 23.A.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY,RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE B. NUMBERS 1.2,3,ETC.OR OX CODE _ NEC ... .. :�{`7";�i 2 C• b I ETt !. , L� 1"'.•i i.{...F-iL 1'� !_.f::, EPSDT VES ❑ NO 1. 2. FAMILY PLANNING YES a a NO PRIOR 4, AUTHORIZATION NO. 24. g, C.FULLY DESCRIBE PROCEDURES,MEDICAL SERVICES OR SUPPLIES F. H.LEAVE BLANK A. PLACE FURNISHED FOR EACH DATE GIVEN D. DAYS DATE OF SERVICE OF PROCEDURE CODE 'DIAGNOSIS E. OR G. FROM TO SERVICE (IDENTIFY ) (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE CHARGES - UNITS T.O.S. LIE I f"i L..ti�I 1 I I I I I I I I I I I I 25.SIGNATURE OF PHYSICIAN OR SUPPLIER(INCLUDING DEGREES(S)OR 26.ACCEPT ASSIGNMENT(GOVERNMENT 27.TOTAL CHARGE 1 28.AMOUNT PAID 29.BALANCE DUE CREDENTIALS)(I CERTIFY THAT THE STATEMENTS ON THE REVERSE CLAIMS ONLY)(SEE BACK) I APPLY TO THIS BILL AND ARE MADE A PART THEREOF) YES o a. Q 31. PHYSICIAN'S,SUPPLIER'S,AND/OR GROUP NAME,ADDRESS,ZIP CODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. i_,i-i{-_�!' ❑:�.'a.I.r1 i'�i�1�(!"i(, '_i-'�•1"•, : __ . DATE: - _. .--1"`i FR.Ptt',J_._...=•L,l.. !_, 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D.NO. 6.".. I.D.NO. PLACE OF SERVICE AND TYPE OF SERVICE(T.O.S.)CODES ON THE BACK APPROVED BY AMA COUNCIL Form HCFA-1500 (C-1) (1-84) Form OWCP-1500 REMARKS: ON MEDICAL SERVICE 5-83 Form CHAMPUS-501 Form RRB-1500 3838 California St.,Suite 715 San Francisco,California 94118 415.668.8010 IOHN N.CALLANDEA,M.D. S� FAX 415.752.2560 0 FREDERIC W.HOST,M.D. OFFICE HOURS ❑WILLIAM L.GREEN,M.D. �U�CiE Monday-Friday 8:30 a.m.-6:00 p.m. 0 TAYLOR K. SMITH,M.D. Q R.RICHARD COUGHLIN,M.D, PHYSICAL THERAPY REFERRAL ❑JON A.DICKINSON,M.D. To crc� c L �L�A INSURANCE PMEnrr PHONE( ) DIAGNOSIS TREATMENT C�-�-/l`1- CI '_\ "+�Z ��L(�4 � L V PREf.AU'1'IONS FREQUENCV l 1C l-'L D1pmoN DATE ©& 0 z- `f 1� 1 �� M.D. 0-107 O v �n oo = � T ao -'' mm �� Z O o Z� ♦� .H m . . -- ND !r m m .p o _ o .r o rn nO n = D Cl) %a m �D W r W to Om pn O m n N 2 Oz to O _z Qj 'fi t!1 rr 00 O F wC 2 0 > OD p _ Om M� fA b m � m Z r br -f m z O m p X m�� me x C r m w m T p Off, C,::8 0 �o o m w --4a �co o5= = 2 c z:�> m cl O b r o ' � n ., z a o .a N � m Ln O �m LnO W O 3 � X m r C� ' .. ... , .p m. Ozzti WO WO0 . 41% 7,� O NZ Z mO: z0 ..� N.P r " Mim O -. Nm _... o 'm E o .w. O - X11 D 0 .. Zn Q ._. m m � < 2 Do C) W n o x. °-o C M 'W ,m " �' co— _ 2 p D O . N.. :-. ,nj �.m.. .0 m r z m:m N J O.: - m n t!f. Cr3. _. r, Z1 m Z �.D D .. c0 ° 0 0 z co�] 0 - x D (n < < m . 7: O O - _ 0 0 m m o aF NI .0 U N a Z Z m MC * z Z C7 c m M. D ') 9F 9 O D: m m T N a 0c N C O -� m n o Z O (n To M � (n O =� N N n a mz; N O lJ1 un O ° m 4 w W e O N • � ? m p (V 0 0 n C Ti L/� ENTERPRISE GENT-•A=CAR _ NTERPRISE RENT-A- Ft COMPANY DF J FFtANCISCD MO 8:00A- 6:00P 7L1 >•��o I:33 `Jrihl idE5a r°JE 415-441-3369 WE $: A- : ::OF T H :�: ,� - - N FRANCISCO .A 941,0.6� 2303 FR 8• DN- 6.00P Sri SU CLOSED YEAR I RENTAL SOURCE + L0. TYPE 50 �-i�•-,rr ❑q9 it • YEAR O RENTER + MILES ._1: T CHARGES IF DIFFERENT ADDRESS HOME PHONE j JL...L_ `.11' UVLi Tr� JI'_l-_`,4-.717pH1 CITY STATE ZIP OFFICE PHONE ORIGINAL VEHICLE LPIF h`'E _= L A 94549 COLOR LICENSE NO. LOCAL ADDRESS I PHONE" MAKE UNIT r DRIVER'S LICENSE STATE EXPIRES `HOURS r DOB HEIGHT WEIGHT vEYES "AIR kl ,GE OUT, L rIw '� / �SOC:AL SECURITY . EMPLOYER , DRIVEN CONDITION Tj IN BILL �— COMPANY TO _ DR/FDR ADDRESS DR/FDR DR/FDR CITY STATE ZIP DR/FDR vATTN: PHONE EXT. OD/GLASS JNKISPARE RENTER ACCEPTS RENTER RENTER REOUESTS PARTIAL DAMAGE WAIdER RENT F\ DAMAGE +OWI AT DAILY FEE SHOWN IN AOJOININC/CpL + by;~_. ,y wl,�- ' r RESPONSIBILITY X UMN SEE REVERSE THIS IS NOT INSURN1 X L.y v 'L COVERSkM.1 RENTER DECLINES RENTER RENTER PEOUESTS PERSONAL ACCIDENT w�VR RE T PERSONAL ANCE IPAR Ai O—V FEE SHOWN IN A04;E TOT 1/9 1/a 3/D��/ ACCIDENT INSURANCE X COLUMN AND HA$READ THE POLICY CERIIFd—ATE -- N E Ye 1/4 3/4 T/s F REQUEST FOR PERMISSION FOR PERSON OTHER THAN RENTER TO QR NOT VALID UNLESS APPROVED i J BY ENTERPRISE'S REPRESENTATIVE 1 -PLACEMENT VEHICLE I request Enteronse's permission to allow T Cq / AGE LICENSE NO. NO O HEI._ o STATE EXP. TAX OR SURCHARGE A O - Tu ^^^ R LICENSE NO. Id 011.e Ine mato,.e mea nerevnder ror me and H my--1n s undersmod g and areed mal FUEL CHARGE swl a resoonvble for nie a..3 wmb Beano I ne anal be under my a,clusi.e conppl and dnectwn and mal na m n01 ine again or seo - ,..,, ant of Enierpr,se �drl^ apse loo Urelr reaoonslbla lo.Ine camolsle IUIhIImam of all Ine terms and conditions ^v ;_IJi UNIT a of Ine wHmn rema tap eem tie I ad acting AUTH.BY X RENTER '') ENTERPRISE'S REP ILE• IN PERMISSION GRANTED FOR VEHICLE TO LEAVE THE.STATE. i STATES AUTH.BY ',GE OUT YES NO ENTERPRISE'S REP TOTAL CHARGES DRIVEN _CONDITION I OUTI IN DR/FDR DRIFDR DEPOSITS I DR/FDR REFUNDS DR/FDR RENTER', DATE I ��. OD/GLASS I X ENTERPRISE c1 ,t� 1' EMPL. JNK/SPARE I I REP X j�J iL COVERSSATE RIC A LU IT, PO E r=- t .v � C�.GS?7-3 )UT E t/e t/a 3/a '/s s/D 3/a 7/a F •AR 5,a _ EP _ - " E 1/8 1/43h '/2 5/3 ?44 7/3F EXT. I DDT'L - - ( PAID cA5 -HECK I = _ TO I I CEP 1 BY CASHEXT. =DC `I RECEIPT FOR CASH PE=JND TO of EXT. AcOTL DATE AF.IC UJT RECdVED TO " BY X TO f CLAIM INFORMATION ADDITIONAL:NFORMA ION' I OR C:. {INSC. 1:.OSS DATE ;yPE n- INVOICE - - COUNTY OF CONTRA COSTA Na s _33 2 6 9 4 WELLS FARGO BANK OFFICE OF.THE AUDRpROpNTROL[ER NATIONAL ASSOCIATION MARTINEZ.CALIFORNIA -:1210(81" _ FUND 8801 MARTINEZ CALIFORNIA ONE THOU SAND• THREE HUN0RE0jHIRTY �ONE'ANDl 726-J100. DOLLARS .VENDOR ISSUE DATE CHECK NO. -_.._ - - .- AMOUNT:'. 00001 05/12/93 332694 MOMTHE:AUDRORS REVOLVING FUND FOR - - TO SNIDER, DANA- - _ PROPERTY,GOODS,RIGHTS OR'SERVICES AS ITEMIZED -- VOID SIX IN PUBLIC VOUCHER ON FILE IN ABOVE OFFICE. IE .3258 _DRIFTWOOD -DRIVE - MONIHS AFTER )ERDATE OF, LAFAYETTECA.:. 9454-9 -...... u'BB0'13.3.269�,u, =-:i; it 2 1000 24B�:4 2 2:.5~=D�� 2,6.L4ii', f. VENDOR NAME' :_ .:`.;:. VENDOR NO.;. ,._.CHECK DATE -CHECK NO. _. REMITTANCE ADVICE= SNIDER DANA 000Dx fl5.J12%93 X326'94 INVOICE DATE ---• - - DESCRIPTION-: =-•" `"'- -= OUR.ORDER NO::-' DISCOUNTTAKEN::.;: _. NET-AFTER DISCOUNT 05/11/93 SET.TL'FMENT'-.-PMT-SNIDER:.: :.: : :: �_;; :�::. ._�.'_: _ : X00 14331.26 _ _. _. - _ (1`' _. V. NTRA COSTA COUNTY AUDITOR,625 COURT ST. TOTAL _00 1,331.2 5 RTINEZ,CA.94553 (41MR 510-646-2191 •J LS LI r... _ OCT 1 51993 CLAIM j 16 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA COUi P��RTll1,`", ++'. Claim Against the County, or District governed by) —BO'ARO—ACTION— - - _ the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT N OV EMB E �, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $7,000 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: WOODARD, Marcia ATTORNEY: Date received ADDRESS: 758 Colusa Ave. BY DELIVERY TO CLERK ON October 14, 1993 (via Risk Mgmt. ) Berkeley, CA 94707 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 15, 1993 JAIL BATCHELOR, Cler eputy I1. FROM: County Counsel TO: Clerk of the Board of Su sors (V) This claim complies substantially with Sections 910 and 910.2. ( j This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying Claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: /I Dated: �C92r, 1 3 BY: Deputy County Counsel 11I. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 5 , M-3 PHIL BATCHELOR, Clerk, By Sd .eA.c� Deputy Clerk 411 WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I Am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. i Dated-" ,.- L2, 19Q3 BY: PHIL BATCHELOR by NI, Deputy Clerk CC: County Counsel County Administrator Clair: to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claim= relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claim must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp f IIA7 & 1 AD 1 ✓�f� ) No DELIVERED ) fi RECEIVED Against the County of Contra Costa ) OCT ' A 19M or ) , District) •� CLERK BOARD OF SUPERVISORS Fill in name ) Co:4TRa COSTA CO. The undersigned claimant hereby makes cla inst the County of Contra Costa or the above-named District in the sum of and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Whe a did the a or in 7occur? Include cit and county) �g j�'Y ( Y Y 'LL How did the e o i c Give full details; use extra paper if 3 damage r injury occur? ( required) .1N1.5 r N+,o +h A I(Z,S Ar _D l , _ ��_z-.�L//,?,5. _----__..-------------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? \OVCr� �. wnat are the nates of county or district officers, servants or employees causing the da,--age or injury? Ca s 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. AttAh two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ---------_ __ �- - ------------------------------ �. Names and addresses of witnesses, doctrs and hospitals. n � � a-kin -- - - --- ---- ----- --------- 9. ist the expendit s you made on account of thiscadent or injury% DATE ITEM AMOUNT /f Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES T0: (Attorne ) . or by some person on his behalf." Name and Address of Attorney Claimants Signature 5 ere Address Telephone No. i Telephone No. Q �D * NOTICE Section 72 of the Penal Code provides: - "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. I€ ' Y y X � � e�