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Home My WebLink AboutMINUTES - 12071993 - 1.41 CONFIDENTIAL COUNTY COUNSEL'S OFFICE CONTRA COSTA COUNTY MARTINEZ, CALIFORNIA MEMORANDUM Date: December 28, 1993 TO: Jeanne Maglio, Clerk of the Board of Supervisors FROM: Victor J. Westman, County Counsel By: Gregory C. Harvey, Deputy County Counsel RE: Adaskin Claim Attached is correspondence received by Mark Finucane of Health Services regarding a potential claim. Please treat this as a claim unless a formal claim has already been filed forlda Adaskin. ' h errithew emorial O . PD�rQL AND CLINICS December 22, 1993 Office of County Counsel Contra Costa County Re: Ida Adaskin vs.Merrithew Memorial Hospital,et al Please find attached copies of the Notice of Intent to Commence Action sent to Helene Holbrook,FNP and Merrithew Memorial Hospital. Mark Finucane, Health Services Director cc: Ron Harvey i Contra Costa County cosy '4 COIIF A-301A (3/87) t, i"I V V" I ' HOWARD & HOWARD ATTORNEYS AT LAW 3732 MT.DIABLO BLVD. SUITE 165 LAFAYEITE,CA 94549 TELEPHONE (510)283-5722 FACSIMILE (510)283-4017 NOTICE OF INTENT TO COMMENCE ACTION AGAINST HEALTH CARE PROVIDER (CODE OF CIVIL PROCEDURE SECTION 364) VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED TO: Hospital Administrator Merrithew Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 YOU ARE HEREBY NOTIFIED pursuant to the provisions of California Code of Civil Procedure Section 364 , that IDA ADASKIN intends to, and will, commence a legal action against you ninety (90) days or more after the date of service of this notice. The legal basis for such action will be that you and the other defendants to be named in such action were negligent in the examination, diagnosis, care and treatment of IDA ADASKIN from approximately. 12/91 through 10/92 . As a result of the foregoing negligence, IDA ADASKIN has sustained injuries, damages and losses of the following types presently known: -Physical injuries consisting of: spread of breast cancer, resulting in radical mastectomy -Medical and related expenses -Impairment of future .earning capacity . -Pain and suffering, emotional distress and impairment of enjoyment of life -Reduced life expectancy. All of the foregoing is based on facts as presently known, and the may be other and additional injuries, damages, losses and expenses still to be ascertained. DATED: December 12, 1993 Keith L. Howard Attorney for Ida Adaskin cc: Clerk of the Board of Supervisors Contra Costa County HOWARD & HOWARD ATTORNEYS AT LAW 3732 MT.DIABLO BIND. SUITE 165 LAFAYE7"I-E,CA 94549 1ELEPIIONE (510)283-5722 FACSIMILE (510)283-4017 NOTICE OF INTENT TO COMMENCE ACTION AGAINST HEALTH CARE PROVIDER (CODE OF CIVIL PROCEDURE SECTION 364) VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED TO: Helene Holbrook, F.N.P. Merrithew Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 YOU ARE HEREBY NOTIFIED pursuant to the provisions of California Code of Civil Procedure Section 364 , that IDA ADASKIN intends to, and will, commence a legal action against you ninety (90) days or more after the date of service of this notice. The legal basis for such action will be that you and the other defendants to be named in such action were negligent in the examination, diagnosis, care and treatment of IDA ADASKIN from approximately 12/91 through 10/92 . As a result of the foregoing negligence, IDA ADASKIN has sustained injuries, damages and losses of the following types presently known: -Physical injuries consisting of: spread of breast cancer, resulting in radical mastectomy -Medical and related expenses -Impairment of future earning capacity -Pain and suffering, emotional distress and impairment of enjoyment of life -Reduced life expectancy. All of the foregoing is based on facts as presently known, and the may be other and additional injuries, damages, losses and expenses still to be ascertained. DATED: December 12, 1993 Keith L. Howard Attorney for Ida Adaskin RECEDED HOWARD & HOWARD ATTORNEYS AT LAW DEC 2 0 1993 3732 MT.DIABLO BLVD. S U17E 165 LAFAYETTE,CA 94549 CLERK CONTR�OF sTACO ISORs 9ELF-PIIONE (510)283-5722 FACSIMILE (510)283.4017 NOTICE OF INTENT TO COMMENCE ACTION AGAINST HEALTH CARE PROVIDER (CODE OF CIVIL PROCEDURE SECTION 364) VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED TO: Hospital Administrator Merrithew Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 YOU ARE HEREBY NOTIFIED pursuant to the provisions of California Code of Civil Procedure Section 364 , that IDA ADASKIN intends to, and will, commence a legal action against you ninety (90) days or more after the date of service of this notice. . The legal basis for such action will be that you and the other defendants to be named in such action were negligent in the examination, diagnosis, care and treatment of IDA ADASKIN from approximately 12/91 through 10/92 . As a result of the foregoing negligence, IDA ADASKIN has sustained injuries, damages and losses of the following types presently known: -Physical injuries consisting of: spread of breast cancer, resulting in radical mastectomy -Medical and related expenses -Impairment of future earning capacity -Pain and suffering, emotional distress and impairment of enjoyment of life -Reduced life expectancy. All of the foregoing is` based on facts as presently known, and the may be other and additional injuries, damages, losses and expenses still to be ascertained. DATED: December 12 , 1993 Keith L. Howard Attorney for Ida Adaskin cc: Clerk of the Board of Supervisors Contra Costa County � � & • ` � t \� � • o . 0 \ 7� � \ � \ � � \ 0 � 0 l # tea # X224 . ct . 0 0�4 0 . 92 % rt 9 7e y . � .. F— ---- — ii .�� _ �— --_ �_ � __ __ __ —_ —^_.—__..�1 S r 1 's `, �: ` w 4 • i . � _� _f . , - � I �� '� ;, _�, rc EIVE-D 6 y �b aa1 HOWARD & HOWARD vXQ H' a n , ATTORNEYS AT LA t/' - iJ' \IY y�'N'/�//�P 3732 MT.DIARLO BLVD. ti SUITE 165 �rV LAFAYETIE,CA 94549 ', ^,�7'�77:I.I?{'MINI: (510)283-5722 (y \�1J" FACSI"L (SIO)265.4017 �' p NOTICE OF INTENT TO COMMENCE ACTION AGAINST HEALTH CARE PROVIDER (CODE OF CIVIL PROCEDURE SECTION 364) VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED TO: Hospital Administrator Merrithew Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 YOU ARE HEREBY NOTIFIED pursuant to the provisions of California Code of Civil Procedure Section 364 ,11 that IDA ADASKIN intends to, and will, commence a legal action against you ninety (90) days or more after the date of service of this notice. The legal basis for such action will be that you and the other defendants to be named in such action were negligent in the examination, diagnosis, care and treatment of IDA ADASKIN from approximately 12/91 through 10/92 . As a result of the foregoing negligence, IDA ADASKIN has sustained injuries, damages and losses of the following types presently known: -Physical injuries consisting of: spread of breast cancer, resulting in radical mastectomy -Medical and related expenses -Impairment of future earning. capacity -Pain and suffering, emotional distress and 'impairment of enjoyment of life -Reduced life expectancy. All of the foregoing is based on facts as presently known, and the may be other and additional injuries, damages, losses and expenses still to be ascertained. DATED: December 12, 1993 Keith L. Howard Attorney for Ida Adaskin cc: Clerk of the Board of Supervisors Contra Costa County AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) " '_ BOARD ACTION the Board of Supervisors, Routing Endorsements, ^) NOTICE TO CLAIMANT DECEMBER 7, 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: $1 ,_000,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: ADASKIN, Ida ATTORNEY: Keith L. Howard, Esq. Howard & Howard Date received ADDRESS: 3732 Mt . Diablo Blvd. , Ste .J651Y DELIVERY TO CLERK ON November 1 , 1993 Lafayette, CA 94549 BY MAIL POSTMARKED: October 29 , 1993 Certified ai 1. FROM: Clerk of the Board of Supervisors TO: `County Counsel Attached is a copy of the above-noted claim, pH g DATED: /9r�y D�a,� , � . /99,� B1fIL DepuiyLOR, Clerk II. FROM: County Counsel T0: Clerk of the Board of Supervisors ( ✓f 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: 3 , j4� 3 BY: �- cam, 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. Dated: 1,. __,Q x.-7,19 �PHIL BATCHELOR, Clerk, By ku , �4aL41 0OA_,, . 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: o��M �,�.. � q.A BY: PHIL BATCHELOR by e A,a1 Deputy Clerk CC: County Counsel County Administrator ' I This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor .does. it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. HOWARD & HOWARD ATTORNEYS AT LAW 3732 MT.-DIABLO BLVD. SUITE 165 LAFAYETTE,CA 94549 TELEPHONE (510)283-5722 ^q //11 FACSIMILE (510)283.4017 r r. , `ECEIVqEwD OCT CLERK BOARD G,:: gid!- RVISORS CONTRA C-)STA CO VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED October :i8, 1993 Clerk of the Board of Supervisors County Administration Building 651 Pine Street Room 106 Martinez, CA 94553 Re: Claim of Ida Adaskin Dear Sir or Madam: Enclosed for filing with the Clerk of the Board of Supervisors is a Claim of Ida Adaskin. Please file this and return a file-stamped copy to the undersigned in the postage prepaid envelope that is enclosed. Thank you for your attention to this matter. Very truly yours, Keith L. Howard HOWARD `& HOWARD ATTORNEYS AT LAW 3732 MT.DIABLO BLVD. SUITE 165 LAFAYETTE,CA 94549 TELEPHONE (510)283-5722 FACSIMILE (510)283-4017 "" RECEIVED October 29, 1993 Clerk of the Board of Supervisors Nov 119M County Administration Building, Room 106 651 Pine Street CLERK BOARD OF SUPERVISOR„ Martinez, CA 94553 CONTRA COSTA CO. Re: Amendment to Claim of Ida Adaskin Dear Sir or Madam: This letter constitutes an amendment to the attached Claim of Ida Adaskin, received 'by the Board of Supervisors on October 19 , 1993 (the "Claim") . In response to the "Notice to Claimant (Of Late Filed Claim) " sent to my attention in this matter, please be advised that Mrs. Adaskin did not discover the professional negligence upon which her claim is based until May 24, 1993 . On that date, she underwent an independent post-surgical medical evaluation by a team of physicians specializing in breast cancer treatment. During the evaluation it was disclosed to Mrs. Adaskin that the cancer in her left breast should have been discovered by her health care providers at Merrithew Memorial Hospital during the time that she was a patient at that facility. In accordance with Government Code Section 901 and Code of Civil Procedure Section 340.5, a claim for professional negligence of a health care provider does not accrue until the patient discovers the negligence. As Mrs. Adaskin did not discover the professional negligence alleged in her Claim until May 24, 1993 , the Claim is within the six-month presentation period. Very truly yours, Keith L. Howard j 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 IDA ADASKIN; 1100 Lincoln Ave.#30 RECD walnut Creek, CA 94596 ) Against the .County of Contra Costa ) OCT and/ or )Merrithew Memorial Hospital,Contra Costa County Health Ser-District) CLERK BOARFill in name CONTR The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 1,000,000.00 and in support of this claim .represents as follows: 1. When did the damage or injury occur?- (Give exact date and hour) Claimant was treated at Merrithew Memorial Hospital from approximately: 12/91 through 10/92. 2. Where did the damage or injury occur? ' (Include city and county) Merrithew Memorial Hospital; Martinez, Contra Costa County, 3. How did the damage or injury occur? (Give full details; use extra paper if required) Claimant was examined for breast abnormalities and underwent mammography. Merrithew Memorial Hospital and its agents and/ or employees negligently failed to properly diagnose and treat Claimant's breast cancer, left breast: ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Failure to properly diagnose and treat Claimant's breast cancer, left breast. (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? Merrithew Memorial Hospital; Helene Holbrook, FNP; Frederick M. Foley, M.I There may be ot_her_employees/agents whose names Claimant does not know. --------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto- damage. Spread of breast cancer resulting in radicalimastectozny; reduced .life ex ectancy; emotional distress; physical impairment, among other injuries. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) The amount of this claim exceeds $2.5, 000; jurisdiction:..in this matter rests in the superior court. 8. Names and addresses of witnesses, doctors and hospitals. Radical mastectomy performed April 26, 1993 at Kaiser. Permanente. Hospital in Walnut Creek. ---- ---------- ---------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 9100'2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by someperson on his behalf." Name and Address of Attorney Keith L. Howard, Esq. Claimant's Signature Keith L. Howard HOWARD & HOWARD Attorney for Claimant 3732 Mt. Diablo Blvd. , Suite:.165 3732 Inst. Diablo Blvd. Suite 165 Lafayette, CA 94549 ,Address . Lafayette, CA 94549 Telephone No. (510) 283-5722 Telephone No. (510) 283-5722 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. The Board of Supervisors Contra Clerk BatchelorBoard a Clerk of the Board and County Administration Building Costa CountyAdministrator 651 Pine St., Room 106 (510)648.2371 Martinez, California 94553 County 1 Tom Powers,18t District Jab Smith,2nd Dlslrlct Gayle Bishop,3rd District �, `•� Sunne Wright McPeak 4th District f Tom Tortskson,5th District ? •r TO: Keith L. Howard, Esq. 3732 Mt. Diablo Blvd. , Ste. 165 Lafayette, CA 94549 NOTICE TO CLAIMANT (Of Late-Filed Claim) (Government Code Section 911 . 3) The claim you presented to the Board of Supervisors of Contra Costa County, California, as governing body of the County of Contra Costa and/or District, on behalf of Ida Adaskin on October 18, 1993 has been reviewed by County Counsel and is being returned to you herewith because: Your claim for an injury to person or personal property which arose on or after January 1, 1988 was not presented within six months of the event or occurrence as required by law. (See Government Code sections 901 and 911 .2) ' Because the claim was not presented within the time allowed by law, no action was taken on the claim. Your only recourse at this time is to apply without delay for leave to present a late claim. (See Government Code sections 911 . 4 to 912 . 2 and 946 . 6) Under some circumstances leave to present a late claim will be granted. (See Government Code section 911 . 6 ) You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. PHIL BATCHELOR, Clerk of the Board of Supervisors and County Administrator BY �-�Z_ !,_ 'CX..�,tX//JJ � Deputy clerk Dated• �//J/�7,9 /ties7T 19 — Enclosure rWx • P� N Ayl rt ct ft C (D W ` P- O rn•� � � F s ko O ¢ tinko CO bd a z P- p m N LTI lull, (Fl .; a m. � o�� oo N fD Ol I-h C! p O � � � �' b 1,0 (D In,p rt cI ®', o O @ Ul Ui ti Lo rt Rl a Lr � S F O Q K N --------------------- p pip ZD00 C m DQ 1 !j r A10 M C z �y 3 CTi� CL CPIno 0 co m k f ,r i t o o - n co D � CFS Ln Er �d � u "i W t LU 4 u, >u ui ft u 1 ?• t9 n . 'f �a cfs d ,. S �� i m 0 �'� o � c �� ` , .� �\ 7 O\, C 1\ �l \ �`'`� �` t�}}/-., '� ��.� �� ,. � �� .` �'�\ � C I r \`l v CLAIM / BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY. CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT DECEMBER 7 , 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: $25 , 848 . 91 + Section 913 and 915.4. Please note all "Warnings". CLAIMANT:MidCoast Trans.portation, Inc ATTORNEY:Carr , McClellan, Ingersoll , Thompson, .& Horn Date received ADDRESS: P .O. Box 513 BY DELIVERY TO CLERK ON November 4 , 1993 Burlingame , CA 94011-0513 BY MAIL POSTMARKED: November 1 , 1993 Certified Mail 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. � PHIL DeTCHEIOR, Clerk DATED: puty 11. FROM: County Counsel f 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: w fi��r.� �- 9 J BY: �. Deputy County Counsel i I1I. FROM: Clerk of the Board TO: County Counsel (1) County A Ainistrator (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. Oated'h, „ �-7 Igg3 PHIL BATCHELOR, Clerk. By Q(fa 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, *Fo"r 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 Po ,,,,,, o Q,. G , I�19 BY: PHIL BATCHELOR by�d, � Q�� )Deputy Clerk CC: County Counsel County Administrator �� l { This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must' be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable' to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. RECEIVED GOVERNMENT CODE CLAIM FOR DAMAGES NOV __ 4 M TO: The County of Contra Costa CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Date: October 29, 1993 1 Re: Approval of Payment and Performance Bonds Issued By Non- Admitted Surety Deduction of Liquidated Damages from Stop Notice Funds Original Contractor: Joe Foster Excavating Project: Highway 4 Widening - SR 160 to Big Break Road Claimant: MidCoast Transportation, Inc. Claimant MidCoast Transportation, Inc. ("MidCoast") was a subcontractor to Joe Foster Excavating ("Foster") on the above- referenced public work of improvement (the "Project") . Foster was the prime contractor to the County of Contra Costa (the "County") for the Project. MidCoast provided trucking services in February and March 1993, but Foster failed and refused to pay MidCoast the amounts due for those services. MidCoast is owed the principal sum of $25,848.91, plus interest since April 20, 1993. Foster, as the prime contractor to the County of Contra Costa for the Project, was required by law and the project specifications to furnish a labor and materials bond, as well as a payment bond, in connection with its work at the Project. The Project specifications provide that the bond sureties shall be satisfactory to the State. The County, as the agency responsible for administering the Project, had a duty to examine the bonds and to determine whether the sureties met the statutory standards. By law, only corporate sureties that are admitted to transact business in the State of California can be accepted. Foster provided a payment bond issued by Old American Insurance Company, Bond No. 290619 E. When Foster failed and refused to maks: payment to MidCoast, MidCoast filed a claim against the bond. Old American Insurance Company denied that it had any liability on the bond, and has failed and refused to pay MidCoast the amount due, or any amount at all. According to the California Department of Insurance, Old American Insurance Company is not licensed to transact insurance business in California. The County should not have accepted bonds issued by this surety. Claimant has been damaged as a direct result of the County's failure to exercise due care in its duty to examine the bonds furnished by Foster, and by the County's acceptance of bonds issued by a surety that is not admitted to transact insurance business in California. In addition, MidCoast filed a stop notice pursuant to Civil Code §3179 et sea. Upon receipt of MidCoast's stop notice, the County had a statutory obligation to withhold funds to satisfy the claims of MidCoast and other stop notice claimants. Claimant is informed and believes and thereon alleges that the County has reduced the funds available to pay stop notice claimants by deducting funds to pay its own claim for liquidated damages based on alleged delays in completing, the Project. The County is not entitled to satisfy its own claims at the expense of stop notice claimants. Claimant has been damaged in the principal sum of $25, 848.91, plus interest. In addition, claimant has had to retain legal Counsel to protect its rights in this matter, and has incurred expenses on account thereof. MidCoast hereby makes claim against the County for these damages. For purposes of communications related to this claim, MidCoast Is address is: c/o Linda R. Beck, Esq. , Carr, McClellan et al. , PO Box 513, Burlingame, CA 94011-0513 . ' Pursuant to Government Code Section 912 .4, the County of Contra Costa has forty-five days to respond to this claim, or the claim will be deemed denied. For further information on this claim, please contact the undersigned. CARR, McCLELLAN, INGERSOLL, THOMPSON & HORN Professional Corporation By Linda R. Beck 14365.1/BG90001.1 CARR, MCCLELLAN, INGERSOLL, THOMPSON& HORN PROFESSIONAL CORPORATION ATTORNEYS AT LAW 216 PARK ROAD,POST OFFICE BOX 513 BURLINGAME,CALIFORNIA 94011-0513 ALBERT). HORN MICHAEL) McQUAID TELEPHONE(415)342-9600 STEVEN D.ANDERSON A. ROBERT ROSIN DAVID C. CARR M' ELOPE C.GI�EENBERG LINDA R. BECK SPECIAL COUNSEL ARTHUR H. BREDENBECK ROBERT W.PAYNE JAMES F. BLOOD NORMAN I. BOOK,JR. KRISTI COTTON SPENCE FACSIMILE(415)342-7685 KENNETH M. HURLEY QUENTIN L. COOK MARK D. HUDAK JEREMY W. KATZ SAN FRANCISCO OFFICE ROBERT A. NEBRIGJJAMES R. CODY JANETTE G.LEONIDOU TWENTY-SECOND FLOOR MARION L. BROWN iORDAN W.CLEMENTS CAROL L. MUSSMAN ONE CALIFORNIA STREET RICHARD C. BERRA PPAUL A. AHERNE November. 1 1993 TERESE M. RADDIE SAN FRANCISCO L. MICHAEL TELLEEN EDWASARAHRD WILLIG III LISA H.STALTERI CALIFORNIA 94111 LAGE E.KEITH P. BARTEL N W. GEORGE�WAILES 11OHBOISE IN T.WALTH ER FACSIMILE (415)(415)362362-1400 MARK A.CASSANEGO RONALD F. GARRITY b.KENT WESTERBERG LAURENCE M. MAY CAROL B. SCHWARTZ PAUL V.SIMPSON LAURA E. INNES DAVID M. McKIM LORI A. LUTZKER CERTIFIED MAIL, RETURN RECEIPT REQUESTED Clerk of the Board of Supervisors Contra Costa County County Administration Building 1020 Ward Street . Martinez, CA 94553 Re: Filing Government Code Claim for Damages Claimant: MidCoast Transportation, Inc. Dear Sir or Madam: Enclosed please find the original and one copy of the Government Code Claim for Damages we are filing on behalf of MidCoast Transportation, Inc. The claim arises from the County's project - Highway 4 Widening - SR 160 to Big Break Road. Please return the copy of the claim to this office, stamped to show the date of receipt. A return envelope is enclosed for your convenience. Very truly yours, Linda R. Beck LRB:em Encl. cc: MidCoast Transportation, Inc. 14365.1/BG90978.1 1:13, ._.2S il'tt:fl;lf� ..t„•.1"(.'. r ..S{ • fir . '� .. .. ) is �J: :}i: W viH o a �j v ` � N 44 E-1 Ma� 00 4) �� H 43 0 ,0 ,0 cla X14, 0 JP E ` 0 N o w co U V U t 4 r � Ozr. p (00 w'Z' � a V c`i m U d V i s 1 • i t CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT DECEMBER" 7; 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:-."Unknown Section 913 and 915.4. Please note all •Warnings". CLAIMANT: DAVIS , Tiffany Lea ATTORNEY: Marsha E. Marovich, Esq. Bennett , Johnson & Galler Date received ADDRESS_ 1901 Harrison St . , Ste . 1650 BY DELIVERY TO CLERK ON Nc)vpmh,-r 89 1993 Oakland, CA 94612 BY MAIL POSTMARKED: Nnvamhar 4 1 9C)'3 Certified P 246 268 736 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. �1 ppNHIL BATCHELOR, Clerk DATED: // w /� /r1 93 BY: Deputy (9-a-'a� 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: f 1� BY: QZ_0Q_,;1 S, LN 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 - Datedc�h o p__-1 )q!3 PHIL BATCHELOR, Clerk, By T, . �a a. Q p�,� 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.-I I ct BY: PHIL BATCHELOR by y ��. �� Deputy Clerk s CC: County Counsel County Administrator r This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it,, waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: MARSHA E. MAROVICH, ESQ. BENNETT, JOHNSON & GALLER 1901 Harrison Street, Suite 1650 Oakland, CA 94612 SUBJECT: Claim of TIFFANY LEA DAVIS Please Take Notice as Follows : The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910 .2, or is otherwise insufficient for the reasons checked below: [ ] 1 . The claim fails to state the name and post office address of the claimant. [ ] 2 . The claim fails to state the post office address to which the person presenting the. claim desires notices to be sent. [ ] 3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4 . The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [XX] 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000) . If the claim totals less than ten thousand dollars ($10,000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ( $10,000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [ ] 6 . The claim is not signed by the claimant or by some person on his behalf. [ ] 7 . Other: Separate claims should be filed for each claimant. VICTOR J. WESTMAN, unty Counsel By: PhiliS. Althoff Deputv County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P. SS 1012, 1013a, '2015.5; Evidence Code SS 641, 664) I declare that my business address is the County Counsel's Office of Contra Costa County, 651 Pine Street, Martinez, California 94553; I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non- acceptance of Claim by placing it in an envelope addressed as shown above, sealed and postage fully prepaid thereon, and thereafter was, deposited this day in the U.S. Mail at Martinez, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: November 17, 1993 at Martinez, California. cc: Clerk of the Board of Supervisors (original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOVT. CODE SS 910, 910.2, 920.4, 910.8) 1 GOVERNMENT CLAIM FOR .DAMAGES jOaJ'��1tif��C 3 TO CLAIMEE: Merrithew Memorial Hospital 2500 Alhambra Ave. LE�4 Martinez, CA 94553 T1G�rE{ �o 5 FROM CLAIMANT: Tiffany Lea Davis 2355 Fifth Avenue NOV .� 9 19M 6 Concord, CA 94518 ADDRESS TO WHICH CLERK BOARD OF SUPERVISORS 7 CONTRA COSTA CO. NOTICES TO BE SENT: Marsha E. Marovich, E 8 BENNETT, JOHNSON & GALLER 1901 Harrison St. , Suite 1650 S Oakland, CA 94612 10 DATE CLAIM ACCRUED: On or about May 15, 1993 11 PLACE CLAIM ACCRUED: Merrithew Memorial Hospital 2500 Alhambra Ave. 12 Martinez, CA 94553 13 CIRCUMSTANCES OF CLAIM: Claimant TIFFANY LEA DAVIS, a patient of Claimee MERRITHEW MEMORIAL HOSPITAL, 14 and under the direct care and supervision of said Claimee and its 15 agents and employees, was treated negligently during her pre-natal period 16 and her labor and delivery which - resulted in the death of her son, GREGORY DAVIS CORBETT. • \ Claimee and its staff failed to properly evaluate, care for and rP 246 268 73� supervise the pre-natal period as well as the progression of the labor of Claimant TIFFANY LEA DAVIS . As a direct and proximate result of the 21 negligence of Claimee and its staff as i alleged herein, GREGORY DAVIS CORBETT i 22 expired. 23 ITEMIZATION OF DAMAGES: The medical bills incurred as a result 24 of the personal injury to TIFFANY LEA DAVIS as well as her pain and suffering 25 and emotional distress . Additionally, the medical bills incurred as a result 26 of the personal injury to GREGORY DAVIS CORBETT as well as his pain and suffering prior to his death. Also, ` damages suffered by TIFFANY LEA DAVIS i i i 1 i f 1 PROOF OF SERVICE 2 I, ALICE MUSSELMAN, am employed in the County of 3 Alameda, State of California. 4 I am over the age of eighteen ( 18) years and not a party to the within action. My business address is 5 BENNETT, JOHNSON & GALLER, 1901 Harrison Street, Suite 1650, Oakland, California 94612 . 6 On November 4, 1993, I served the within: 7 GOVERNMENT CLAIM FOR DAMAGES 8 on the parties to this action by placing a true copy thereof 9 in a sealed envelope, addressed as follows : 10 Merrithew Memorial Hospital 2500 Alhambra Ave. 11 Martinez, CA 94553 12 /xxx / (BY MAIL) I placed each such sealed envelope with postage thereon fully prepared for first-class mail, for 13 collection and mailing at Oakland, California, following ordinary business practices . I am readily familiar with the 14 practice of BENNETT, JOHNSON & GALLER for processing of correspondence, said practice being that in the course of 15 ordinary business, correspondence is deposited in the United States Postal Service the same day it is posted for 16 processing. 17 / / (BY PERSONAL SERVICE) I caused each such envelope to be delivered by hand to the addressee noted above. 18 (BY FACSIMILE) I caused said document to be 19 transmitted by Facsimile machine to the number indicated . after the address(es) noted above between the hours of 9 : 00 20 a.m. and 5 : 00 p.m. 21 I declare under penalty of perjury under the laws of the State of California, that the foregoing is true and 22 correct. Executed at Oakland, California, on November 4, 1993 . 23 24 1 25 Alice Musselman 26 CONFIDENTIAL COUNTY COUNSEL'S OFFICE CONTRA COSTA COUNTY MARTINEZ, CALIFORNIA MEMORANDUM Date: November 9 , 1993 TO: Clerk of the Board of Supervisors FROM: Victor J. Westman, County Counsel By: Gregory C. Harvey, Deputy County Counsel Re: Claim of TIFFANY LEA DAVIS Attached is a claim forwarded to this office from Mr. Finucane of Health Services . Please process in the usual way. errithew emorial O�CP04Qd AND CLINICS November 5 1993 Office of County Counsel Conta Costa County Re: Tiffany Lea Davis (son: Gregory Davis Corbett, deceased) The attached claim,regarding the above named patients,was received by Merrithew Memorial Hospital on this date by certified mail. 4?r/� Mark Finucane Health Services Director enc. xc: Ron Harvey �GUrlgl ®unsei NOV - 81993 ,Vfartlnez, CA 9455 Contra Costa County cOsra cooK`�'t,� _ A-301A (3/87) CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT DECEMBER 7 , 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, al l "Warnings". CLAIMANT: -EVONC , Mi chan R. ATTORNEY: Date received ADDRESS: 2600 Jones Rd. Condo 1 BY DELIVERY TO CLERK ON November 9 , 1993 Walnut Creek, CA 94596 BY MAIL POSTMARKED: November 8 , 1993 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppHII BATCHELOR, Clerk DATED: � 3 I . 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: ll BY:_1 Deputy County Counsel 111. 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. /J Dated: q 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*,__� C�q BY: PHIL BATCHELOR by ��,,a �caC,, „ ) Deputy Clerk CC: County Counsel County Administrator This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of' Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. _- — nc • ___ __ __ __ �- _ - - - -- - _- - _ - - - --- - I __ _ - - _ �- _� _ - �- I W AT SPY. 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 December31, 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 nfust be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administratiom• Building, 651 Pine Street, Martinez, CA 924553• 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 M1CNAM FZ. EV014C ) � RECE9VED _Against trie~C �:.^*y.of Contra Costa ) NOV _ 9 or ) CLEFIK BOARD OF SUPERVISORS Fill name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the Count3► of Contra Costa or the above-named District in the sum of $5®e�, not) ;__0-0 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. --------------- --- - - -- -- - 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) SE E ATA CN ED ------------ DN _�t� _ , - _---Q.EA1,_L_AC=_1L MAf C'4LE1 3. How did the damage. or injury occur? (Give full details; use extra paper if required) ------------------5_EE_A' �1AM---------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused. the injury or damage? (nvPrl ' e 5. What are the names of county or district officers, servants or employees causing the damage or injury? U BRA,RjAt� ---—--—------------------5LEELMEEAm=----MY AILROL�I-A_-Abddlb ISTRAMN 6. 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.) ------------- ——------- 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 Gov. Code See. 910.2 provides: SEND NOTICES TO: (Attorney) "The claim must be signed by the claimant Name and Td—dress of Attorney or by some person on his behalf.'i ra fLn-tirs SY-g-nature) I _QUgAddress Telephone No. I Telephone No. c1f;Wq 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 officer, authorized to c - board or 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 ($10,000, or by both such imprisonment and fine. Name M ICHAp� EVENAULDE EVO&Q, Address q(M Cn U ffr STT M A R JJ N EZ _Cf� COC or 10 Number SUPERIOR Cc URT, STATE CAU F00A IN AUD EOR CONTRA COSTA MULCT`/ EXPERIMENTAL PETITION FOR WRIT OF HABEAS CORPUS Petitioner vs. No. S ENU M a$oW*d by a.A of Ow C4uml Respondent ` INSTRUCTIONS — READ CAREFULLY • This petition must be clearly handwritten or typed.The petitioner must sign under penalty of perjury. Any knowingly false statement of a material fact may result in a conviction for perjury. You should be very sure that all answers are correct. • Read the entire form first before answering any questions. Complete all applicable questions in the proper spaces. If you require additional space, add an extra page and indicate that your answer is "continued on addi- tional page' • Notify the Clerk of the Court in writing if you change your address after filing your petition. • if you are filing this petition in Superior Court,you need file only the original and one copy unless local court rules require additional copies. • If you arefiling this petition with the Court of Appeal,file the original and five copies. • If you are filing this petition with the California Supreme Court, file the original and ten copies. - • In addition, the law requires the service of a copy of the petition on the district attorney,city attorney or city prosecutor in certain cases(See Pen.Code, f 1475; Gov. Code, f 72193). You may serve by mail. • Rule 56.6 provides,"The petition for writ of habeas corpus designated"experimen- tal" is approved for mandatory use by petitioners in Marin,Sacramento, San Ber- nardino, or San Luis Obispo Counties who file in the superior court,the court of appeal. or in the Supreme Court.Any superior or appellate court in the state shall accept the experimental form for filing and process it the same as any other peti- tion for a writ of habeas corpus. For good cause, a court may also accept for filing a petition that does not comply with this rule:' Approved by the Judicial Council of California for use under Rules$6.6 and 201(f)(2)of the California Rules of Court (as adopted effective July 1, 19901. AOC-512b This pc itioO concerns: A conviction Parole A sentence Credits X Jail or prison conditions Prison discipline —! other (specify): Di=& AL LE ACC-ESS M C(lt\R`f' 1. Your name M i C-B Mil R EN A t S L1 E ENCAAC 2. 'W%crc are you in custody? M A R-M1 E Z LL'T E EEC)" FACWV t V 3. Why are you in custody? E<1 Criminal Conviction Q Civil Commitment a. If criminal conviction, state nature of offense (for example, "robbery'? GRA N 'l i 1-1 E FT b. Penal or other code sections P. C G 1 as B , P. --- c. Name and location of sentencing or committing court _SOPERR\nR C-CURT CDAT RA C(- STA CO t �MTV '7 EPT t?-- 4. ?d. Case number e. Date convicted or committed 1:�-4 1 19 qa f. Date sentenced s S. Length of senteoee S t X M(�,Nm S. h. When do you expect to be released? D ECFM-RF=�PZ \a, \9 g g 4. What was the LAST plea you entered?(cbeck one) Q Not guilty Q Guilty M Nolo Contendere Q other S. If you pleaded not guilty,what kind of trial did you have? Q Jury Q Judge without a jury Q Submitted on transcript Q Awaiting trial 6. Did you testify at trial? Q Yes Q No AM-512b Page 2 7. GROUNDS FOR RELIEF Ground 1: Suit briefly the ground on which you base your claim for relief.(For example."the trial court imposed an illegal enhance. tnent")If you have additional grounds for relief, use a separaie page for each ground. Pages I and S are designed so you can stare grounds 2 and 3. For additional grounds,make copies of page S and number the additional=rounds in order. I)EWAL CF Ansi S�_ A CV--- 170C k\-1, LA&I BCf1KC It R ES EA Rc h1 v4 i 1 iL� CO=MES ca r 'FOR. C' iVtL LITiC-�ATirA - Ci1i1L .RULES CSF C,C>ltRT', a. Supporting facts: (Tell your story briefly without citing cases or law. If you arc challenging the legality of your conviction. brKf. ly describe the facts upon which your conviction is based. If necessary. attach addirional 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 rt:sult in the denial of your petition. (See In re S%vin (1949) 34 Cal.2d 300. 344.)A rule of thumb to follow is: who did exactly what to violate your rights at what time (when) or place (vAere). If available, attach declarations supporting your claim.) E-aTFL`f At\IT) SE/ERp,t_ OT"EB PR O— PARS: SE NTiiWC� Amen t Q SENTNC_M t�(M\k HAVE BELL UIEETE"n LAW Rne-�Ks, 0 tyl t L FR Int S . LIEG,A t M ATER t ALS A to D CTH I R Wk CE TO nct=ct,1-C) , RESPc)ND C)R BR.tN1CtVtt_ LIT< c,A' i ni\A CC 0,11 L S ITS FC)R `DAM AC,ES, PER'�C)IAAL i NauR�� DAM) SLIPPnP-T, �R-rc, Ate D CR MC500Q; TC) SET ASID- _ / ITt all , t-1 t Ln cusTCD� T�.xT REAt_ csTra^r� oR c�-i E Ct�j\l_ `nc -nc Til Y�AT�:-- l4A.1L Ai L-3 FE E I A L EPA Qt t P-D . ALL �a�r r�r= -VAAF- PRC zj=cTuC `Tj4etyR FtGWT.S W1 CC�t\RT 14AVE Mt T b. Supporting cases: , (Briefly discuss or list by name and citation the cases which you think are factually close to your$ as an example of the error you believe occurred in your case. If necessary. attach an erten page.) IOC-512b tinge 3 e \Al_I I--O- L ci 15��1_��_ Qt�LYC LM_i_NAL A D N -T-h_ -WsTxNT MATTE-R �CtSI__�t�1_ER LESRN �At=1N A Q �1 I� V�ILQLJ-t S Rq Imo_ P_P QGES —KIQ ESP BL.I Com'_'7 C tq—U= --ASR-EK��Dt FZI_ LA SLS o� soa ccs,Cyn—w- t- T nk %E� PEC)CESS, 0 M.RTC til S �3LA 1-1-L_t�41—�U�S�� W v-z--RE' 1_G Ns2� ��1� TL�S P�3s2�LL1�I_N U�PRC�CE=SS AND ��L PRdT�i 1.QI�l GI�USE� �tM C�SST_T�&I FS NN-CuF L1T�__A ��N1S i ClT1aN-m- ► R ESS of PUN AE kA P ERR 1. /J ,t Ground 2: (if applicable): Dt�l IAL OF ACC ESQ -TCS ouR OPtoNG- AtAD IDIPLAVtNF-, LEGAL MAIL tAC)7 IIS THE ' F'F��SC-�1 CSE �F 111 M ATS k-2,9,EACH CSC- CLRFtL>5010A JTq Ate ) y10RK P ML0CT E-1RkV I EG a. Supporting facts: DP\I I A.L C I(SIM-ACE OR REPOSM 17) PERM IT' WMA-VE-7- OSE OF LAW- LI RRAR-\1 REFUSAL PERM IT PETITTC)hJ ER POSSESSION AML> USE CE LAW R , LEGAL �Z»Rl�at_�, C� tQLiCAT(c�N�S, C�1RRE�lT LEC-,AL RESEARC1--1; tNFORML,nnCA tilCST' C)OLI HAS 1 MPT PE11T(c)M ER -ACCESS Ta COURT lI1 T 1 NTFKM LI IA L 'IFN I A L. CST= PETS I ILQEE RIC--.H-T CE A(`r��S TCS C nURT A R C A uSt= Pin�n c2 N ER CLWt-rNtli� EMWLMIC DAMAc-_t=c 12MyC L O UNCIAL REPAIR (^AUSI (�I DLAMACED BC 1h TO PETt 11OVER AEM HtS '[=AMiL-Z 11,IC'ulD1KIG ETIUDONAl r PET170C)NI ER HEALTH C CIU c-1 rotJ Sar H i C H t fJ rt D ES 14 k(IIA IRL-LL,D AU) PCbR " ART . -MIR vJ t LLE(_1[ AhAO CNLI t 11� WFUCc' UARM , \AIR H iS CRuV=L A\tom\D tJtJWS, 3A 1 Put�tsNryt�r ttJ �1toLA�lotJ b. Supporting cases: of A.00•512b Page 4 Ground 3: (if applicaMt): t ELAL. (0)F PRoPCR FMMPTMr-4 7, Tti PEW817PR , PESS , CAR?Y--N PARR , S OL;'S t11-- CNV;?,T L iCAL_ , ,C----TATF ,, SET) SRA l REN C E MINIAL .AsN n CM L, , F=AI t_11RE MPRnV1D ACC.��S -ML_,y/ 1 t RR,AR Y CES (�L1 I EI AREA FOR R EA RCR AsswAtlCE r--RcM �k. Akur-im PROFESSIOVAAL OR �ODWLEt)G '�1H INMATE E a. Supporting face: 1S CR1 SL. ANZD bNUSUAL PMS'YiME%7, RETM o9 RC MA LAW C LCF Y, ASID M E ti CA L h l VR M P�b 1 CAL MIA 1` IOIA• Wk►k Ck4 AT -nMIP-q MA-V�rS M �M--Eclll M 'WRITE (,P . IWT) PESLtLM LE -n M V' AS, R EFQI\t R E� W H EIS! PR 5- DRAW-!M Cn C�R nPAr--1�r°A,, Lpr AL \�I��C�t�l C,, F1 �. �Cit fel. ► C, , P FrI n c\c,1ER AS A S1SLT ?1� 1-115 �I,SARILI` A 1AAS D�r)ST�,/ `� M A-AC-Tl t-CR A -r /?,P\-klgi ER - ` F07 nt1P7 7r� Asr)VAWl r ` ECHMN.LGq 1= -*�S.SESSFSI Nn 1 s(InmCNA L u R F AT `n .STA Irr LR C1`t FR lKIMAT12S ., IH AT DEN 1 A L. C-U V,TlA C(�WM NAL 1 IW"I"1 WT 7r) I MPH OT .'PU K 19AME 7JA7 R- k\nr i=TAR°A ARE ARAP,.MT t)LI;" TO N IWMATE W R *BARE 'FUNI). PEM- NMFR HA,,,, Cnt A-n Kl 1A L1 V PQ1QT NT 714AT N,!;7171-MOIA L PnLI Cy . IS WITT`HWI L(;:C,(MA-rE G.-inVERSMENTAL PORP b. Supporting cases: woaSlse Pw 5 N D K�i_6VJ�CC2ll_1�S�Q�/�Y �EI�EI3�1.�.LY�_K SYS-E-E-M.A-D-C -LLY V �E_`CLTI b.NS_�kSPE f�LL� l�_�tl_I�1n1'R_►_1T_El�l_.-LN�-LL�J►_1�1 LCA Ll 'i E_S_1nLl-k_I_�H�l_NT�3.E !A-Cf-E- SCC)u EsS_CZR �sSx Rio LtsiIES _�Li� I c �_�T_1 aR S /Ey EsT_l�►�T L W-BOOKS-,_L�_c-A'L �=-Q u3PR�►Ci_ P E u- R F-E_LT- E-Ws f LA-V1�a�U§�N_g �T� �tS��t_E S�( CdURSSt�Llo�iR�i_ilS _E LL�F u L rel_ IT- QFB<C> i V_E F i-VA iE 1A-M E-iT_��IS .SSS _i H P R�I ISI Al� �1�1 EES T-) (S la� Com_( _MATS_ 1 Sl-i V0OWA A— Q R CN IM� E_C 1� _tf-- O_Cp_i\I EIJ�DALt / n NST TO Pi-LVATcy P_EN_I_I�GAF LAG-�L_�1A�L_�t�1�EQF�C1_la(G--L1 MA�E T_0 S-ECOR P_HoT0—CoPt_ESCNE -C-za_tK�r_�oTI-QN_P_F-H-eA P, M.�t�.. _SU�RCES k IR � —L-LEV_o U.S A IT) /A—S uRL T_'(=oF M QV(_NTLL�(-D-A CLCxnI . Acc'— zH-E W--LI-BR-A y ID CC)N I�LST N_�l_QE1�1�7 AL L.E�_,- I_ copytN(� S��icEs. R_ES EA,R---t P-R-E-BA MS�T191I C3 _I-EES/-W A ENTAL�s�N Ss7TS��1U i�t��_Li�7�t«�®N A. D V DLAT-i _k--P-RCY,-SS�At�- '=,�).lsA-L�. CIEC 7N— G /tet V ' \ y` �'- , E _ 4 � 4 y ' } Cly US E_O F TN E U�1_t-t ED-S�AT�S C�.N ST_IT�T_1 O_N Y X11-5_I N_TR t,�si_ON__OF DEN_y_1N� /�_ccEsS _ T- �.A1A1_.1 1 B_RARy -_ EQ 1 BESTS 70-B _D_1P._'E:C 1_ED Ate\_D >'10_WT_OR Ep _ _IA-M_A 1_E PRA-0-LEGE-0-F-8 te_EACH�_1 N_V_ TI aTION-UR __ CON_�=I_D ENTl AL—SO U I CES tai OT u R E�Blj _ D 1 S�_LCUS IS;E�C�_T +Z�_T_'ECT_S_ _P_ QPC��_I_T=I01, Oa _ P_ET_f_Tl ON ER- L_RTN_ T7�T_ES AT IS-DE \JAL --__ _A CTS__�S AN 1 NTENT1�N_A�—I_l\ITEM I D�1T1.01�1-T0_L_F_OR __6At_LAFU L_i N S_T_-t_T_"U_-(7_oNAL OR . GCV_ERN_MlN_L i c_TET-_�VFERNN _I_D R_-C=S EA C1A/-C_0P_I:S _ Q-1 R__A_C_CESS T_Q OQUR_I_____1_S_i N-tel RE'C 1 CO REtATT_o_N._ T-TN t---LU_NG OEA HAQEAS O2 _.?_M �t�". �T C:uA_I_NI O'R_CO_l�R O�A UTY�tpR_I_Ty V 1.011�T1C�t� �ISTiS_UT10N—OR--aC,_V_ER_N_M_C(__I S lA_F_�, OC�EN11�\G Q_F_LE-G.A_._MAI1_O-ACE_MIGR_7__L_� u_N I_NTEN_DQ�1A_L_o_AFT - -.-- SFV RA_A_G t\AP_ =6 k_N_TU-4 i_L �B y PET_`Tl0 MERA- -----___-- COI�IST_TTUm_aAm-R_l_C r ' I � _ •} _��.�� _ _ r; S � � .. T ., l�l_O ON:L`l IT THEl CR cQ�C M Et�1T Q M.At_L—B uT W 1-l_A_______�__-.-----l�ct_\_L-� —_.-- LZA----- ,At�1�CR�ACN M ANT O_F �QN t=1 DII�TI/�,L_I`�e_PE�t-1 TI ON_trR— t�(A i ES E EA-8 R oN—W--i-_El`l—TIUEY ----- — R ES N_S_ S CN F_i LTi A.�.- f ' . 1 8 Nave you attached copies of all relevant records,trznscripts or other documents supporting your claim?(For cxarnpie. if you claim you were improperly sentenced, attach a copy of your sentencing transcript.) Yes Q No 1f n(x, explain why not. &EES\ M(y,7 CsgIc—, t�lAl_ '(y'clwF--M-T MLL esE P-Rc)rwcE) N �ARIZ.IG 9. If your claim is of the type for which there are administrative remedies.did you exhaust these remedies?(See In Re Dexter (IM) 25 Cal-3d 921. 925.) Yes No If not, explain why M. FtL_En =R►CVA�ir�� CRIEVAt� , " PQOC-E"ReS 1 GtZRM Attach documents which show you have exhausted your admi iistrauve remedies. 10. Did you appeal from the conviction. sentence or commitment? Q Yes Q No If yes. continue with number U. If no. skip to number 14. U. Give the following information about your appal: Name of court("Court of Appal" or"Appellate Dept. of Superior Court.") Result Date of de dsion Case number or citation of opinion Issues raised (a) (b) (c) (d) (e) AOC-SM Page 6 12• Did you sock rc%-Icw in the California Supreme Court? Q Yes Q No Result Date of decision Case number or citation of opinion Issues raised (a) (b) (c) (d) (e) 13. If your petition makes a claim regarding your conviction or sentence which you or your attorney did not make on appeal. explain why the claim was not made on appeal. 14. Outer than dkw appeal,hm you previously Mod any pedtiotu.applications,or motions with respect to Ns conviction or commitment in any court? . Q Yes. If yes. continue with number 15. Q No. If no;skip to number I& noc•512b Ngc 7 o. (1) Name of court Nature of proceeding (for eximple. "habeas corpus petition') Issues raised (a) (b) (C) Result Date of decision (2) Name of court Nature of proceeding Issues raised (a) (b) (C) Result Date of decision (3) Nam of court Nature of proceeding Issues raised (a) (b) (c) Result Date of decision AOC-512b Page E 16. 1f there were more prior petitions, applications or motions, provide the same infornation on a separate shad. 17. Did any of the courts listed in number 15 hold a hearing? Q Yes Q No If yrs. state name of court, date of hearing, nature of hearing, and result. 18 Explain any delay in the discovery of the claimed grounds for relief and in raising the claims in this petition. (See In re S%vin (1949) 34 Cal.2d 300, 304.) 19. Were you represented by counsel during trial? Q Yes Q No If yes. state the attorney's name and address. 20L Were you represented by counsel on appeal? Q Yes No If yes. state the attoracy's name and address. 21. Me you presendy represented by counsel? Q Yes Q No If yes, state the attorocy%name and address. 22. Do you have any petition, appeal or odw Matter pending in any court? Q Yes Q No If yes. explain. ,roc-stzo Page 9 3 1f this petition might lawfully have been made to a lov,cr court,sutc the circumstances justifying an application to this court_ 1, the undersigned. say: I am the petitioner in this action.the above document is true to the best of my own knowledge, except as to matters that are stated in it on my information and belief. and as to those matters I believe it to be we. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on (darel:SC�V 17M B ER ---Iq �SGR at (place!: M ART!RE Z Q ET r--NTI 0 M ';7AQUTY- wIli J-1 , tSgMt�x�1 Comments and suggestions on this vW intental form should be sent to Legal Section.Administrative Office of the Courts. 595 Market Street. San Francisco. CA '94105, before August 15. IM AOC-S72b Page 10 w ITh Nc,in.trs� s., ws .ilr„m1Ii TC ','/0 rSrf��:J� V o r � � , ,, i �� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT DECEMBER 7 , 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: $888 . 38 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:MAI SS , Barbara ATTORNEY: Date received ADDRESS: 1°78 Elminya Drive BY DELIVERY TO CLERK ON November 2 , 1993 Pacheco , CA 94553 BY MAIL POSTMARKED: Hand Delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. py1L BATCHELOR. Clerk DATED: py 11. 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). ( ) Ciaim 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 �9�3 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. BOARDD 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._L ,,&,7 \99�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 warnino 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 „g,M„p , 4 I q 9 BY: PHIL BATCHELOR by � Deputy Clerk CC: County Counsel County Administrator �c9� This warning does not apply to claims which are not subject to the California Tort Claims. Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any 'of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. 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 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 . ID DELIVERED 3��gIq►eIa I�A;S s RECEIVED d /�8 �"�M��yip .J��✓c- �/:Iq c qac=co ) Against the County of Contra Costa ) Z or ) District) CLELLF4S74PERS Fill in name ) CONTRACO The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the -sum of $ 9,9S 5A and in support of this claim represents as follows: —__________ 1. When did the damage or injury occur? (Give exact date and hour) .Tuc y �, t 9 9 �- /Q 3° q, r-7. ---------__—------a_________ 2. Where did the damage or, injury occur? (Include city and county) S1DEu/A11e A.AQE,q IAJ 1-_i20A17- OF /� n 53 9 9 �iac��e�o ✓.� �/ �IE�U 0NT� C.o sf/� Laur✓ry _ - ----------------- 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 of county or district officers, servants or employees caused the injury or damage? G/N�vE/✓ ��1�EGr//�G� � L/aG'/� Off' /��i�✓T�ill/�yC�� (over) 5. Wnat are the names of county or district officers, servants or employees causing the darmge 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. ------------------------------------M-YNN--�� -Y-Y------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) �E� /l9C��L-J C'Or/.oGlT�i/U/V ----------------------------------------------- --------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. .D,e. JoNxIly �ic� 1�f9/ �'r-�.9.�wao> �i�a/c, Su:r�/� /:-711--1A5-19.v.,71✓, 0/57 A/-5 G -------------------------------------------- --__ ----------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ,,ITEM AMOUNT 2T4 � Gov. Code Sec. 910.2 provides: _ zS ;•:" " "The claim must be signed by the claimant SEND NOTICES T0:--- (Attorne ) - or by some person on his behalf." Name and Address of Attorney 46 Claimant's Signature Address Telephone No. Telephone No. 5-/0 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. BARBARA L. MAISS 178 Elminya Drive Pacheco, California 94553 .?7 . � /0 3 Q.yrs. , �Gv� OY! •�� - d(t� 70', 0 G''�� U� u�lu�c� �Q�� Yui. l�� `�� • HI!/I2 �, �� c. calla" ` u�� U� Q• ,c2�z'�� Lh c..A� �� 0 nese 1�z BARBARA L. bIAISS 178 Elminya Drive Pacheco, California 94553 o1f 4,11f�147e Off/ �Z'a4laZ�4&w- ch V+oi� auae- ,14 c,h tl4yavl t-� azle a'w"Fu;��42�� v9,tfar�t.,d u o Ak 65�a) BARBARA L. M4ISS 178 .Elminya Drive Pacheco, Cali f ornia 94553 Ft>�cr�G xor eavz De. !"�o 11 Eigv 7a 004 .?X .!�2• f? Low - Jia i«rt n�v �y/3 r�,4,-le/r1 8G n1t S )e 5� �� s a2 X 41e. 0. / iC� — i'Z -,4Sr9AO-V +/ t1Sr�iiE SIT�lSdrl�Ges x.24 = .3� 7 C L o rt///!/G .sE S,ea.ers 9,y ,�os.s or- `'mac r/Qiv /7//V,61 fz 7 rweoau xl 1-1u&u,5r 3 0 lo -assist us in serving you, piease inciude Employee -Information employee information and patient name when . Check 001630042 you direct inquiries to: Employee MAISS, B SS Number 550580345 ST. LOUIS GROUP CLAIM OFFICE Group Number: 10955 P.O. BOX 120 BALLWIN MO 63022 TELEPHONE: (314) 821-3002 Hancock Use 0002/0101/0001/0001 Explanation of Benefits FOR SERVICES PROVIDED TO: BARBARA MAISS (A) (B) (C) (D) Provider/ Service Total - Deductible - Coinsurance = Plan Paid Service Date(s) Charge Amount i Amount i D RICE, MD OFFICE VISIT 08/06/93 40.00 40.00 100% PODIATRIC PHYSICIAN OFFICE VISIT 08/03/93- 64.00 64.00 100% 09/02/93 XRAY 09/02/93 35.00 35.00 100% SUN VALLEY URGENT 'C OFFICE VISIT 07/27/93 71 .00 71 .00 100% TOTALS: 210.00 210.00 Payments Made.To: 10/12/93 BARBARA MAISS 210 . 00 Page 1 of 1 'LEASE RETAIN THIS PORTION FOR YOUR RECORDS John Hancock Mutual Life Insurance Company, BOSton,MA 02117 )rm H-390 Ed.3/91 Printed in U.S.A. n i io assist us in serving. you, please include Employee -Information employee information and patient name when Check # 001591354 you direct inquiries to: Employee MAISS, B SS Number 550580345 ST. LOUIS GROUP CLAIM OFFICE Group Number: 10955 P.O. BOX 120 BALLWIN MO 63022 TELEPHONE: (314) 821-3002 Hancock Use 0002/0101/0001/0001 J Explanation of Benefits FOR SERVICES PROVIDED TO: BARBARA MAISS (A) (Bl (C) (D) Provider/ Service Total - Deductible - Coinsurance = Plan Paid Service Date(s) Charge Amount % Amount % DRUGS/MEDICINE 07/29/93- 88.35 �' ��sxa <— 22.09 257 66 .26 75% 08/15/93 GENERIC DRUGS 08/07/93- 15.20 Or 15.20 100% 08/10/93 . D RICE, MD OFFICE VISIT 07/29(93- "'90.00 22,50 25% 67 .50 75% 09/08/93 /ytic 1 ozr' TOTALS: 193.55 �� a 44.59 148.96 Payments Made To: 09/24/93 BARBARA MAISS 148 . 96 Summaries FOR BARBARA: $768.21 REMAIN TO REACH YOUR MAJOR MEDICAL OUT-OF-POCKET LIMIT FOR THIS CLAIM PERIOD. Page 1 of 1 PLEASE RETAIN THIS PORTION FOR YOUR RECORDS John Hancock Mutual Life Insurance Company, Boston,MA 021 Form H-390 Ed.3/91 Printed in U.S.A. SO VaGy c�>� • 1 I00 Contnz Co6ta Boulevard Cor>roond CA 94523 IRS X68 0M268 514825-2000 9 FAX 510-825-0861 DISURMWE Pn Mder#=91375Z PATIENT r ` PATIENT I.D. 1 FEE TICKET NO. DATE I(t'i. rf'11'•l:Ytir,l 1"_ L .L . � 71-" LI. i1 . CP TREATMENT E.M.CODE AMT TREATMENT CPT AMT TREATMENT CPT AMT INITIAL OFFICE VISIT SURGICAL PROCEDURES SUPPLIES 1 99201 1 81 I&D Subcutaneous AS, 10060 201 Cervical Collar 99070 2 Office"! 99202 t 84. Remove F.B.Subcut 10120 203 Cradle Sling 99070 ice Visit 87 Debridement of Wound 11000 204 Elastic Bandages inch 99070 4 Office Visit 99204 88 Bum,Small,Debride b Dress 16020 220 Knee Sleeve(Neoprene) 99070 5 Office Visit 99205 92 Removal F.B.Conjunctiva 65210 205 Knee Splint(Small, Med.,Lg.) 99070 52 Office Visit-Modified 09952 95 Removal F.B.Comes 65220 206 Splint Finger 99070 100 Removal Impacted Cerumen 69210 r234 Splint Wrist 99070 ESTABLISHED PATIENTS-OFFICE VISITS Air Cast Ankle Splint 99070 8 Office Visit 99211 SPLINTS/10 YRS AND OVER Tennis Elbow Band 99070 9 Office Visit 99212 333 Short Arm Splint 29125 Elbow Sleeve 99070 10 Office Visit 99213 335 Short L Splint 29515 Thumb Spica Splint 99070 11 Office Visit 99214 Eye Irrigation Supplies 99070 18 Office Visit 99215 MEDICAL PROCEDURES-DIAGNOSTIC Eye Tray 99070 52 Office Visit-Modified 09952 142 ECG with Interpretation 93000 226 EXT.Tray 99070 01421 Audiometry 99552 210 Surgical Tray 99070 .PHYSICAL EXAMINATIONS YNT GYN Tray 99070 18 /School P.E. 99201 IMMUNIZATIONS/SKIN TEST 615 Suture Removal Tray 99070 19 Work/DMV P.E. 99202 181 Adulf Td 90718 211 Suture Material X 99070 163 1 M - M - R 90707 213 Dressing,Small 99070 LACERATIONS-SIMPLE REPAIR CPT 164 1 Polio 90712 ressin I"nt'er'M'ed18t'e5 99070 25 To 2.5 cm,Scalp.Extrem.etc. 12001 1661 TB / PPD 86580 232 Dressing,Large 99070 26 2.6 to 7.5 cm,Scalp,Extrem. 12002 176 Influenza 90724 221 Crutch/Rental 99070 027 7.6 to 12.5 cm,Scalp, Extrem. 12004 27 To 2.5 cm,Face,etc. 12011 MEDICATIONS(IM,IV,SUB-O,INHALATION,ORAL) REFERENCE LABORATORY-DAMON 400 Injection 90782 301 1 Collection& Handling 99000 LACERATIONS-INTERMEDIATE REPAIR 402 Epinephrine 99070 317 CBC 6 Platelets 85023 35 To 2.5 cm,Scalp. Extrem.etc. 12031 406 Demerol/Vistaril 99070 340 SMAC 25(Lab Scan) 80119 36 2.6 to 7.5 cm,Scalp. Extrrn. 12032 407 Rocephin 99070 604 Mono Screen 83608 37 7.6 to 12.5 cm,Scalp, Extrem. 12034 410 .Pulmonaid 94640 305 Urine,Culture / Sensitivity 87086 40 To 2.5 cm,Neck. Hands,Feet 12041 346 Culture/Sensitivity Other Site 87070 45 To 2.5 cm, Face, etc. 12051 LABORATORY-IN HOUSE 296 Stool culture/sensitivity 87045 303 Rapid Strep Test 87060 Stool ova/parasites 87177 X-RAY 309 KOH Prep b Wet Mount 87210 DNA Probe 87178' 50 Chest 2 Views 71020 311 Urinal is,Dipstick 81002 360 HSV Culture 86695 52 Ankle 73610 312 Unnal sis,Complete 81000 306 RPR 86592 53 Foot 73630 314 Pregnancy Test Urine 81025 086 HfV Ab 86701 54 Knee 73562. 644 Fingerstick Glucose 82947 601 Pre Marital - M(RPR) 86592 _ 55 Toes 73660 0644 Fingerstick HCT 85013 602 Pre Marital - F(RPR&Rub) 86762 56 Elbow 73080 Occult blood in feces 82270 600 Urine Drug Screen' 80100 57 Finger 73140 ` 58 Hand 73130 MISCELLANEOUS 60 Wrist 73100 0352 Dictated Reports 99080 Medical Records 9000. PHARMACY PHYSICAL THERAPY#3270 185 Any Comb.Mad. &Prot. 17720 186 Ea.Add 15 Min. 97721 DIAGNOSIS O Abcess/Cellulitis 682.9 O shoulder - 923.00 O Otitis Media,acute382.9 'O Hand/wrist 727.05 O Abdominal pain 789.0 O too(s)and sub-ungual 924.3 O Otitis Media,Serous 381.4 O Shoulder 72&10 O Abrasion,corneal or scleral 871.9 O wrist 923.21 ❑Paronychia 681.9 O Upper Respiratory Infection 487.1 O Allergies/hay lever 477.9 'O Degenerative disc disease 722.6 O Pharyngitis 462.0 O Urethritis,nonspecific 597.80- O Allergic reactions 995.3 O Dermatitis: O Pharyngitis,Strep 034.0 O Urinary Tract Infection 599.0 O Bronchitis,acute 466.0 O allergic/contact 692.9 O Pheumonia 486 O Vaginitis 61&10 O Bronchitis,asthmatic 493.9 O poison oak 692.0 O Pyelonephrifis,acute 590.10 O Viral Infection 079.9 O Bum,any site 949.0 O F.B.eye 930.9 O Rash 782.1 O Warta,any kind 078.1 O Cerumen,impacted 380.4 O F.B.Soft Tissue 729.6 O Sinusitis,acute 461.9 0 Wound(Puncture,laceration, O Chest pain 786.50 O Fracture:O ankle 824.8 O Sprain&Strain: animal bite,etc.) O Conjunctivitis,acute 372.0 O finger(s) 816.00 O ankle/foot 845.00 O Face 873.40 O Confusion: O ankle 924.21 O fool 825.20 O arm/Shoulder 840.9 O Finger(s) 883.0 O arm 923.9 O hand 815.00 O cervical 847.0 K Foot 892.0 O back 922.3 O wrist 814.00 O elbow/Forearm 841.9 O Forearm 881.00 O chest wall(ribs) 922.1 O tools) 626.0 O finger(s) 842.10 O Hand 882A O elbow 923.11 O Gastroenfentis,acute 558.9 O hip/Thigh 843.9 XLeg 891.0 O finger(s)and sub-ungual 923.3 O General Medical Exam V70.3 O knee/Leg 544.9 O Scalp 873.0 O foot 924.20 O Headache.Tension 784.0 O lumbosacral 846.0 O wrist 814.00 O hand(s) 923.20 O Headache, Migraine 346.9 O thoracic 847.1 O head/neck/face 920 O Insect bite 919.4 O wrist 842.00 O knee 924.11 O Laboratory Test V72.6 O Tendonitis O leg 924.5 O Otitis Externa 380.10 O Elbow 727.09 DIAGNOSIS IF NOT LISTED ABOVE - PLEASE PRINT DIAGNOSIS CODE . 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"� '-j'f /`^ I-.(�,ti' .��p►�i:c •',�?�•- t Jrl 7 r•'a �l> Cr~lp(f1'i�'a1��i� ' 01-111%, J�'1�' `'�,(l !' �'1ry:\•� (, rliv.-ft1�a4>�sr�1 •7 Iw...r.:.iS ;•'._. ll�.y ti, .tir �-..^�".'�.. t+.,/fr".1 • ' - y -`• 1 • 1.I { •l r•U Iii" ��;.. �r�1( .�J J�.�1��, • ,� I. jZ4 .-t ,1�J�;'r�.•• l,�l�R 1 ^lad I�rj'-��! ry J?t�I r1J c1)I�i�� i)�J� �t Ilt/,► 1 �'. r(s Ti_I r�T_T;��i..Y;t•Yi'r'S1�•�'C%r[f�,l..._�i��T•�i.�-��r,�� -: !:i.�..:, fly=J r.t�.l .�,. • 1 / I t r 1 ME I Lp •'� • ell• DONALD RCE,,M.D. 1491 CEDARWOOD'LANE, SUITE A 7` LIC.#G20252 PLEASANTON,CA 94566 IRS#94-2166790 ( s 3 510)846-7789:. 0 PRIVATE 0 MEDICARE D HMO/PPO 0 OTHER PATIENTS LAST NAME FIRST' T AY'S DATE 0 ,�` G ASSIGNMENT:I hereby assign my insurance benefits to be paid directly to the I have been by Dr.Rice that tate services shown on this superbill/release undersigned physician.I am financially responsible for non-covered services:I also may be denied by my,Med!Care Part Bas medically:unnecessary.1 agree to be authorize the physician to release any Information required to process this claim: personally,and fully responslble for these servk:es: SIGNED:(Patient, SIONED:.(Patient or Parent of Minor) or Parent of Minor) ✓ DESCRIPTION CPT/Md FEE /I DESCRIPTION CPT/Md I FEE V, -DESCRIPTION` CPT/Md FEE OFFICE VISITS CPT-92 NEW EST. OFFICE PROCEDURES ;;�• IMMUNIZATIONS Minimal(Inj./UA) 99211 EKG 93000 .NIMR`< 90707 Focused 99201 99212 / EKG Tracing Only 93005- Influenza. 90724 Expanded 99213 Holter93225 P. B 90731 Detailed 99203 14., Holter Interp. 93227 ,Pneumococcal' 90732 Comprehensive 99204 99215 Spirometry 94010 Tetanus Toxoid' 90703 Complex 99205 Sigmoidoscopy 45330 Maj.Svc.Int.Visit 99025 Sig.w/Bx 45331. ".THERAPEUTIC INJECTIONS Ear Lavage 69210 Vitamin B12`.`" J3420 90782 Trigger Pt.Inj. 20550' DelesVogen$:.. - 90782 CONSULTATIONS OFFICE Small Jt.Inj. 20800' Testosterone 90782 Focused 99241 Major it.Inj. 20610' Dego M '.'_ 90782 Expanded 99242 Audiometry 92557 Detailed 99243 !&D 1006M LAB` Comprehensive 99244 Mlcio.Exarii-.,- 87210 Blood Sugar Finger Stick 82948 Occult Blood 82270 MISCELLANEOUS Udnalysis 81000 Supplies 99070 Mono Test- 86403 Copy of Records Rapid Strep• 87081 TS Intradermal 86580 Coli,do Hand. 99000 ICD-9 DIAGNOSIS: 0610.1 Cystic Adenosis 0053.9 Herpes Zoster,NOS ❑535.5 Peptic Gastritis 0 789.0 Abdominal Pain 0 595 Cystitis 0 272.0 Hypercholesterolemia- 0 462 Pharyngitis,Acute 0 706.1 Acne 0300.4 Depression,Psychogenic ❑272,4 Hypedipklomia 0451.2 Phlebitis,Leg 0477.9 Allergic Rhinitis 0309.0 Depression,Situational 0 401.9 Hypertension 0451.0 Phlebitis,Superficial 0 565.0 Anal Fissure 0 692.9 Dennatitla,•Contact:Allergic. O 242.9 Hyperthyroidism 0 486' Pneumonia 0565.1 Anal Fistula 0250.0 Diabetes Mellitus ❑272.1 Hypertriglyceddemla. 0 692.6: . Poison Oak 0413.9 Angina Pectoris 0562.11 Diverticulitis 0257.2 Hypogonadiam(Male) 0589.0 Polyp,Anal or Rectal 13300.00 Anxiety 0562.10 Diverticulosis 0244.9 Hypothyroidism O V22.2' Pregnancy O 429.2 ASCVD 0 692.9 Eczema 0380.4 Impacted Cerumen 0427.60 Premature Beats 0 780.7 Asthenia,Fatigue 0604.90 Epididymitis O 564.1, irritable Colon 0 601.0. Prostatitis 0 493.9 Asthma O 530.1 Esophagitis' ❑386.30 Labyrinthitis ❑427.0 PSVT O 427.31 Atrial Fibrillation 01381:81 Eustachian Tube Dysfunction 0464.0 Laryngitis. O 729.2 Radiculopathy 0 35.1_0 .Bell's Palsy 0 704.8 Foiliculitla 0 846.0 Lumbosacral Sprain/Strain Cl 714.0 Rheumatoid Arthritis ❑796.2 Borderline Elevated SP 0727.43 Ganglion 0 683 Lymphadenitis,Acute 0724.3 Sciatica 0 800 BPH 0558.9 Gastroentertft 0627.2 Menopausal Syndrome: 0 706:2 Sebaceous Cyst 0 490 Bronchitis,Acute 0 V70.9 General Medical Exam ❑346.9 ; Migraine T780;2,-9 Seizure Disorder 0112.9 Candidiasis 0242.0 Graves Disease 0746.6 Mitral Regurgitation: 73;9 Sinusitis 0354.0 Carpal Tunnel Syndrome; 0784.0 Headache,Facial Pain 0 424.0 Mitral Valve Prolapse= Syncope O 847.0 Comical Strain 0307.81 Headache,Tension 0278.0- Obesity;-= 0727.00 Synovitis Tendinitis 0786.50 Chest Pain 0578.1 Hematochezia 0715.9,.-, OsteoaAhdtls0.465:9: Upper Respiratory Int.,Viral 0574.2 Choletlthiasis 0599.7 Hematuda ❑733.00, :.. . _ 0599.0 Urinary Tract Infection ❑428.0 Congestive Heart Failure 0.455.6 Hemorrhoids,External O 387_,W 00s;_Mediak- 01616.10 Vaginitis,Non-Specific 0372-30 Conjunctivitis. 0553.3 Hemia.Hiatal 0381;4'- Otil1s'.wdta;semus:,; 0 780:4'- Vertigo 0564.0 Constipation 0550.9 Hemia,Inguinal 0 380:10 '134W` Otitla;-Exlema, 05362, .Vamiting/Hyperemesis 0496 COPD 0722.2 Herniated Disc O V72 3'. 134 Annual O 0733.99 Costodwndritls 0054.9 Herpes Si NOS.. 0 533 8 Peptic yGseaselUloar '' 0.r- DIAGNOSIS:(IF NOT CHECKED ABOVE) NEAPPOINTMENT: DAYS WEEKS IrWN AOCE!?T 4 0 YE$O FIO'DOCTOR'S SIGNATURE/DATE XT f" • • •• ja 1. Complete the patient portion of S. Patients with health care insurance,plosse rerrmember TOT AL TODAY'8 FEE your insurance form. A.Professional services are txrarged tp the patient,and'rat to the OLD SALANCE 2. Sign and Date. insurance company: x BTOTAL 3.Attach this-form to your B.Insured patients are expected to take cane of their fees as seMces� insurance form. are rendered. 3 AMOUNtTfREC Q_TODAY 4. Mail directly to your InsuranceC.This office cannot accept responsibllily,forcoOecting:your InsurBtrce BY C1CashrtOCheCk C`;. company. claim,or for negotiating a settlement on disputed claim fi fi ., NEYY BALANCES- ;�_ DR . ' MARGARET LOWE PODIATRIC PHYSICIAN $ SURGEON ID 540506360 4179 PIEDMONT AVE . STE 201 ( 510) 655-8435 LICENSE E234'2 OAKLAND, CA 94611 8-3-1993 NAME : MAISS BARBARA ID : 550580345 DIAGNOSIS : 92430 PROCEDURE : 992.12 CHARGE': 32 . 00 TOTAL : 32 . 00 PAID : 32 . 00 CONTRIBUTING DIAGNOSIS : , THIS IS YOUR ITEMIZED STATEMENT FOR SERVICES PROVIDED IN THIS OFFICE . THIS STATEMENT CONTAINS ALL DATA REQUIRED BY YOUR INSURANCE COMPANY . USE THIS STATEMENT WITH THE MEDICARE EOMB FOR SECCONDARY INSURANCE COVERAGE , i k ' S DR . MARGARET LOWE PODIATRIC PHYSICIAN & SURGEON ID 540506360 4179 PIEDMONT AVE . STE 201 (510) 655-8435 LICENSE . E2342 OAKLAND, CA 94611 9-7.-1993 NAME : MAISS BARBARA ID : 550580345 DIAGNOSIS : PROCEDURE : 99212 CHARGE : 32 . 00 7362124 35. 00 TOTAL : 67:00 PAID: 67.00 CONTRIBUTING DIAGNOSIS : THIS . IS YOUR ITEMIZED STATEMENT FOR SERVICES PROVIDED IN THIS OFFICE . THIS STATEMENT CONTAINS ALL DATA REQUIRED BY YOUR INSURANCE COMPANY. USE THIS STATEMENT WITH THE MEDICARE EOMB FOR SECCONDARY INSURANCE COVERAGE. A . KT ,eww vAw Vjvow,anc, 1 O&AW 4225 ROSEWOOD DRIVE PLEASANTON, CA 94366 f 580 CENTER AVENUE MARTINEZ,CA 94553 460-8552 24 HR.REFILL:460-0937 I ® PHONE 370-8077 4 07/29/93 Rx # :t:58'--343 � 08/07/93 Fix # ;R4-=9ts7� *S.ILVADENE`. PC":CREAM.. ! *SSD- I% CREAM COMMON USE (S) FOR THIS DRUGI COMMON USE (S) FOR THIS DRUG: . To treat skin infections To treat skin infections associated with 'burns. . associated with burns. HOW SHOULD I USE, IT? HOW SHOULD I USE IT.? Consult doctor or Consult doctor or pharmacist for proper. pharmacist for proper application rnethad. Follow ; application method. Follow your doctor' s instructions. your doctor' s instructions. ARE THERE. ANY..:S.IDE EFFECTS? ARE THERE ANY SIDE, EFFECTS? Burning, redness: stinging. Burning, redness, ' stinging. Very unlikely, but report : Very unlikely, but report : Rash, itching, breathing Rash, itching, breathing problems. problems. II p f i d&rgrs VAtq th9'trPs,A1iC. 4225 ROSEWOOD DRIVE PLEASANTON, CA 94566 560 CENTER AVENUE MARTINEZ,CA 94553 460-8552 24 HR.REFILL:460-0937 PHONE 370-8077 07/29/93. Fix # �_R t!;8-=943 08/07/93 FZx.#. _., iE:4'DE5,'t57 Mii I SBs> BA' -; MA I SS,, BARBARA.. RBARA:, 178 ELMINYA DR,:,-, 178 ELMINYA DRIVE PACHECO, CA 94566 PACHECO, CA 94553 RICE, DONALD (' ME3 _ .. RICE, LDONALD MD °PRICE $7. 00 - PRIEE $7. 15 #20 SILVADENE, IPC CREAM #20 SSD 1% CREAM (MR1 (KC) NDC#bOf26 aSfJtr=' _ _ EDS 10 NDC#F00048-2100- _ EDS 5 REG # PH , .s REG # PHY34550 - SAVE TIME USE OUR 24HR REFILL 24 HOUR REFILL HOTLINE- . LINE # 460- 0937 MON-SUN ! ! ! ! _.....- 370-1484 1i :_a 9P q I =1111111 3 H4 D OcL F m c fV f A'; nGf'CT r-iiCr'T +;,C=li}T i''i TT' iTcu r;:ir m C o 'rr;71';NTGl�, A6 ffi,i rJu i n„r,n� 7c•l t:J Or{ 4v {R J t G `�0.1 <<� i�}.jj �ia AL?i1r_ 7-.L_,iiLC TLrAV i T r A 7C tT '+ 1�1 m n LONGS DRUG STGFs J � a ' a � � 7 FLEASA�lTON - C ` m m j c iJA:-+A4 c•c•n -TyTrrc= i ; s 3 1 a� i 3 Fa Ga LLfr �T T,T 7.is L: iT Z 10 4629 251 IAr• TSIC Fri Ca'' T i 10 3 m i f n h7 +=. OGr+rt i_.j�i.1} -•. eT `tri ri (T 1 7 0.6 "L•iiLTirT'.i i7 � � w � JON-STICK' PAD IT 57 �7r„ it O -1 11.4 i%t i c ?GTt PTY T,':,'r :OF i EJBCHCMBR IT 4:,77 _!:RTiITA� 59,9,x'' r:�Jr! -'ure•!_:- o rtt 7?S� ?� +3Y/^t G4 1 ;1n 'rr}i.%AT rni.uC:. x '�rJf;A:iiii:7 tZ_ri r,t i 4Q1 "may c y;t h, y It AA :25 S TAX .9j tri 'iiiiJi .i, _ ,�•- 7'r,jl 7c f±Y!G! �'f1S Q rJr3 TOTAL2i7, fp '31-1 , q��t� 49 50M4.99 S� St!5T13TAL 4 6 99 210 F,n `I•{�i+NG i rIRGI �% i;i,:,'c70r, )5Y Tx + hf 7101-491491004'. ACCT- I r�RHiy�}1�{:, +Tr1J_ 1'II ._ ii''7''ji't77 Hi I Lil'i�t._ ,_A J•(,�} .. r'TM1 1 lTT .r' S ^Ili!! DRUG .,;}J�.0 .I� ..,,-.. .!T i:.iTw_ i L OO v Tri -ii l I:Ai iri 7 i !K YOU FOR S1kG AT LONGS ee�� ,� IPi7, s ear 7ti 3y !E BEST DRUG Std-Rt,,IN TOWN' :91 1993 251' 6:R`N I TO PAY AB TOTA AMOUNT` iRDING TO CARD ISSUER"AGREEMENT SALES SLIP __--- ------------ --------- CUSTOMER COPY _. - -CUSTOMER COPY 16 9 0 4 9 s NOT REQUIRED IF CHARGE CARD IMPRINTED ; Add;.: apt. IQ7 CityiSt.:Zip:- } _ � !c: Cc 4•j c Credit{�Uth.: a4 Uj CO O F— ~ x Ul Vj C-A "This purchase is to be charged to my account and will be.paid for in. accordance with my charge account agreement. EMPORIUM reserves a >; C'. >, a e U-i f PURCHASE MONEY SECURITY INTEREST,as provided for in said agree �`t =i rr C r i r•� cY } ;rY Qi lri KT 6• C> C; Q•• 1 a ment,in the goods purchased until paid for in full." ,p .,r� „� ,�,. •�- V t O C, r`.. 14 r-•. Cid, Cs C'+ �J CG f`•. O C•, p cc -- ` r s e.', K, tom+ �. L1.. I OO - - EMPORIUM 'I x dT T6QUT r W—S—T SERVICE IS :itB ONE A7/7Q/43 70RE=013 074 9552 12!19 096 01 �57n01 FILM DEVELOP i T 5,99 SEARS t)7 567001 FILM DEVELOP IT 6:119. CONCORD, CA 13681 A317nfi FTi MM TDEVEL 1?P 1 T( a.nv (4 947170 RETAIN FOR CO ISI WITH MONTHLY - - _ 05 ?471,B3 3m DISPENSER IT STATEMENT OR FOR RETURN ORD _ r - - - 06 9d7501 C1IRITY TELFA 1 T + �� _:..: - --_ 07 94711-7 NEOSPORI.N IT {, TM PG/STORE REG# AMr„ 047757 BAND AID IM +T 7 10 8421 10 O1 8 10? 638 -=-_- .__ 09 022A0151TORAGE ;:t+3v, 7T 4^:00I 9TY 7 tia F,00 EACH SALE SUBTOTAL 73.91 07 85 M14 FUSCHIA,SKO �ff 11.99T70 T= 8,215 Y, TAX 6110 SUBTOTAL 11.99 -- _ -. --- _ :- TOTAL TAX .99 WM1768934878/0 -- MASTER CARD CHARGE 30,02 07/30/93 HE TOTAL 12.E -- -- = .�CrOUNT NUMBER � 5410654004091416 00 A 70??19 "YOU CM COUNT ON ON ME" -.. 9, �s 1 INDICATES SALE PRICE �n PURDWED LOB-my omm _ A EENENT, INCUMTED BY REFERENCE, J"" - ---- THANYS FOR SHOPPING AT STARGET , , 0 I GRANT SEARS A SECURITY INTEREST - - _.___. -..__ f TltT $ BA+:t'. TO OUR COMMUNITIESI IN THIS DISE UNTIL PAID SOH EVERY PURCHASE 'SINCE 196-2 UNLESS PROHIBITED BY LAN X. .......................... =�D�BY� SALESCHECK # 013681078421 SEARS THANK YOU FOR SHOPPING AT SEARS �� CONCORD, CA 1568-11 N q sou RETAIN FOR COMPARISON WITH MONTHLY STATEMENT OR FOR RETL SRN iOR EXCHANC;E TRAN# PG/STORE REG# ASSOC# 31?21' 10 t'1.368 307 1 cN-. SALE 1� 07 3-53-1014 PRINT S.ORT MISE 17.4. 7 %495016 GREEN. '�HTN MDSE 11.99T (7 40403037 SKIRT PRINT MIq- 14,99T SUBTOTAL 44,')7 TAX 3,71 46817034MB /0 07./30/93 SEARSCHARGE TOTAL 48.611 "YOU CAN i�iNT Qra ME" PURCHASED L)NDER MY SEARSCHARGE BARBARA L. lel RISS` t 178 El nin ya Drive Pacheco, California 94553 ` _ t _ 1 ��• r�5o 4b E�i3 gg�:sa: NAME ------ - - - -- PERIOD TIME REGULAR TOTAL F.I.CA. S.D.J. INC.TAX STAT PER.BEGIN. ENDING WORKED NET PAY , S.S.• EARNINGS DEDUCTIONS DETACH AND RETAIN THIS STATEMENT LAWSON'S STATIONERY&GIFTS-BERKELEY,CALIFORNIA 94704 -r .,, -=^l"+^?.'��z. -. ---.--. - -_-,--- - •.. _-- fir*+-,--e.-�•- ++m.-+.-•.-.--77 .. NAME _.__.... _- PERIOD TIME REGULAR 70TpL F.I.C.A. S.D.I. INC.7AX STANTIE PER.BEGIN. ENDING WORKED NET PAY s-s•0 EARNINGS DEDUCTIONS DETACH AND RETAIN THIS STATEMENT LAWSON'S STATIONERY&GIFTS-BERKELEY,CALIFORNIA 94704 -•-` - -- '.- '_, -. .. _ .. ... .. _._. ... ..:. .. '. •..'., -.., _ - .. � icy .... .. Y NAME — -- _ PERIOD TIME REGULAR TOTAL F.I.C.A. S.D.I. INC.TAX STYE- MGb.C^RA PER.BEGIN. ENDING WORKED NET PAY' EARNINGS DEDUCTIONS S,s.• DETACH AND RETAIN THIS STATEMENT LAWSON'S STATIONERY&GIFTS-BERKELEY,CALIFORNIA 94704 �. Qd•� I B�a`I43 ICU b.U'O 11.50 l0.'3� Loi•09 �M.•la �S 19' `. 8'S'�f. :,. NAME REGULM TOTAL F.LC.A. S.D.I. INC.TAX - --PER.BEGIN.BEGIN. PERIOD TIME TAX HEA ISA NET PAY ENDING WORKED EARNINGS DEDUCTIONS S•S.• DETACH AND RETAIN THIS STATEMENT LAWSON'S STATIONERY&GIFTS-BERKELEY,CALIFORNIA 94704 a ' `. _ BARBARA L. MAISS 178 Elmin ya Drive Pacheco, California 94553 n 120 Igo s +_. 1�t-T. ;,� �� v �_i—_�•t� �.£Fy��'�.r�iC. -t:., �.;V. _ _. i ' vi a s � _s s� �.�� • - � :a,.._ ..'^Erb ;e . s � ,t - - .0 - tVj e BARBARA L. MAISS 178 Elminya Drive Pacheco, California 94553 r F, 1 i i 1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT DECEMBER, 7 , 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: $4 , 500. 00 + Section 913 and 915.4. Please note all "Warnings". CLAIMANT:THORNE, Nancy Lee Administrator of the Estate of Ewell David ATTORNEY:Deborah K. Patterson, Esq . Law Offices of Borden D. Webb Date received ADDRESS: 906 G Street , Suite 630 BY DELIVERY TO CLERK ON November 8 , 1993 Sao,ramento , CA 95814-1813 BY MAIL POSTMARKED: November 4 , 1993 Certified P 056 383 435 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ',,� IVIL BATCHELOR Clerk DATED: ��_(�.� Zo, /9 93 61: BATCHELOR, 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: 1 I1 _ 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. BOARDD 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. /I Dated: 1 PHIL BATCHELOR, Clerk. By ( ,,a,(7 O,L,� 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, p n Dated 1,, 9 . Iqq BY: PHIL BATCHELOR by ,c{, , ( ' gay Deputy Clerk CC: County Counsel County Administrator A I I J This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of ' its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. l� - 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, 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 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 To—rm. RE: Claim By ) Reserved for Clerk's filing stamp NANCY LEE THORNE, Administrator) of the Estate of EWELL DAVID ) TERRY REC7ED Against the County of Contra Costa ) NOVorDistrict) CLERK BOARD OF SUPERVISO Fill in name ) eor�TRA c)STA co. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 4,500 plus attorneys' and in support of this claim represents as follows:* fees and costs 1. When did the damage or injury occur? (Give exact date and hour) On or about May 24, 1993 2. Where did the damage or injury occur? (Include city and county) Police impound lot located . at Templers Auto Body, 2505 Devpar Court, Antioch, California, County of Contra Costa ---- -------------- ------ ---------- --- 3. How did the damage or injury occur? (Give full details; use extra paper if required) See Attachment - 4. What particular act or omission on the part of county or district officers, servants or employees caused the: injury or damage? The panel truck was stored-.at the directionof the county employees-' at an unsafe location, resulting in the loss. i (over) . What are the names of county or district officers, servants or employees causing the damage or injury? ' Unknown 6. What damage or injuries do you claim resulted? (Give full extent_ of injuries or damages claimed. Attach two 'estimates' for auto damage. _ $4,500, plus I.Xs ' fees and costs_ ___ �M_�____�____________ 7. How was the amount claimed.above computed? (Include the .estimated amount of -any prospective injury or damage.) Appraised value of 1953 GMC panel truck isX41500---------------------- 8. Names and addresses of witnesses, doctors and hospitals. None -------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Attorneys' fees expended to recover the value of the 1953 GMC panel truck, in an-.amount to';b-e- calculated at the conclusion of this matter 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 DEBORAH K. PATTERSON, Esq. LAW OFFICES OF BORDEN D. WEBBaimant's Signature 906 G Street, Suite 6.30 c/o LAW FFICES OF BORDEN D. WEBB Sacramento, CA 95814-1813 906 G Street, Suite 630 Address Sacramento, CA 95814-1813 Telephone No. (916) 447-1675 Telephone No. (916) 447-1675 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. Attachment On or about May'21, 1993, a GMC 1953. panel truck.(one half ton) ("panel J truck"), California license no. 2CLD831, was recovered by what was thought by the claimant to,be the"Antioch Police4Department and•placed,under=their control and supervision. On or about October 21, 1993, claimant's attorney, Deborah K. Patterson, was advised by Will Venski that the panel truck in question was actually recovered by the Pittsburg Police Department, whereby at the direction of the Contra Costa Sheriffs Department, the panel truck was placed in the impound lot located at Templers Auto Body, 2505 Devpar Court, Antioch, California. On or about May 24, 1993, said truck was stolen from the police impound lot. APPRAISAL REPORT of 1953 Gt is 1/2 Ton Panel Delivery j Prepared For Ms Nancy Thorne Pittsburg, California By David Jacobs Executive Director AUTUMOBILE APPRAISAL ASSOCIATION Date of Vehicle Inspection August 27,, 1791 Sonora, California s PURPOSE AND SCOPE OF REPORT PURPOSE The purpose of the report is to estimate the market value of the vehicle described herein as of the August 27, 1991 inspection date. MARKET VALUE DEFINED The Fair Market Value of the vehicle is the highest price on the date of valuation that would be agreed to by a seller , being willing to sell but under no particular or urgent necessity for so doing, nor obliged to sell , and a buyer , being ready, willing, and able to buy but under no particular necessity for so doing, each dealing with the other with full Knowledge of the vehicle. METHOD OF VALUATION The value is estimated by market data comparison supplemented by cost information . The vehicle is compared with others for sale and that have sold in the general time period. Adjustments are made for differences in equipment , mileage , cosmetics, sale terms and current economic conditions. ASSUMPTIONS AND LIMITING CONDITIONS Information provided by the owners, parties to sales and others is assumed to be reliable but its accuracy is not guaranteed. 7: ,T A U T 0 14 0 B I L E A P P R A I S A L A S S 0 C I A T I O N 14 GALLI DRIVE NOVATO, CA. . 94949 (415) 332 2556 August 27, 1991 Ms Nancy Thorne 352 Santa Ana Drive Pittsburg, California Re: Appraisal Report 1953 GMC Panel Delivery License No. : CA 2CLDS31 Dear Ms Thorne : In compliance with your telephone request of August .26, 1991 have appraised the 1953 GMC Panel Delivery Truck license California number 2CLD831 , located in Sonora, California. The enclosed Appraisal Report, constitutes our analysis and conclusion of the above referenced vehicle. The Fair Market Value as of August 27, 1991 inspection date is Four Thousand Five Hundred Dollars "as is where is" . Thank you very much for this assignment. Please call me if you should have any questions.. Very truly yours, iExecuti I DeDirector DJ/pd i• LT IDENTIFICATION AND DESCRIPTION OF VEHICLE AUTHORIZED APPRAISAL This narrative is an attempt to determine a valuation as of inspection date August 27, 1991 . DATE OF INSPECTION: August 27, 1991 DATE OF REPORT: August 27, 1991 LOCATION: Sonora, California IDENTIFICATION OF VEHICLE CAR MAKE: GMC MODEL YEAR: 1953 BODY TYPE: Panel Delivery MODEL: 1/2 TON I..D. NUMBERS: A228492599 10122CI5239 LICENSE NUMBER: CA 2CLD831 EXPIRATIO114 DATE: MAY 1989 TAB NUMBER: D7791325 ODOMETER READING: 00256 MILES DESCRIPTION OF VEHICLE EXTERIOR COLOR: Yellow INTERIOR COLOR: Brown EQUIPMENT: 8 Cylinder Engine Automatic Transmission Custom Wheels Grant GT Steering Wheels Roof Vent CONDITION OF VEHICLE Body Metal : Fair - rust bubbles visible at rear area, unrepaired damage at right rear fender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paint: Poor - The paint has oxidized and the door jams are mismatched and not refinished. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trim: Fair - The front grill is damaged.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . Bumpers: Front - Fair Rear - Poor bracket damaged. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Caskets/ Need replacing Window Seals: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tires: Fronts/Goodyear Eagle GT's P205/60 R 15's Rears/ Goodyear Eagle GT's P255/60 R 15's Tires on the ground appear roadworthy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carpets: Front rug missing - Rear area worn . . . . . . . . . . . . . . . . . . . ... ... . . . . . .. . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . Seating: Front _eating good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . Door Panels: Missing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interior Metal : Fair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MECHANICAL: The appraiser was unable to test drive the subject vehicle. SUMMATION OF VALUE: Analysis and Conclusion Our conclusion as to dollar value is based on the following; The overall cosmetic appearance as viewed The demand and available supply of comparables. Dollar amounts indicated by value guides. The subject vehicle as inspected on August 27, 1991 in Sonora, California is to be considered an incomplete example of a converted 1953 GMC 1/2 Panel Delivery to a "Street Rod" As described on the condition page the exterior paint finish is far below the usual for a street rod conversion. The body is in need of restoration with the rust problem and the unfinish repair to the fender area. The interior of the vehicle is in need of major refurbishing; there is an obvious older restoration showing wear, age , and usage . Mechanically the actual condition of the vehicle is unknown ; it was reported to the appraiser there was a transmission problem. The engine and transmission conversion reflects major expense; however the subject vehicle has been stored for a long period of time and the engine and transmission condition is unknown. Included with the report are value guides suggesting retail sale prices for "stock" examples. The alterations and modifications both cosmetic and mechanical totally change the catagory and retail value of the vehicle . The urle of the guide is only for general overview rather than direct retail price comparison . Additionally contained in the report are examples of street rods available and for sale at the market place. Asking prices fluctuate depending upon the overall cosmetic appearance and condition, originality, the. mechanical history and performance, recorded mileage, and configuration of power train, options, and accessories. It is to be noted there are no 1953 GMC Panel Deliverys listed for sale. The vintage, series, and body style. is in demand at the market place. Based upon the on site inspection of the subject vehicle and with consideration for all information and dollar amounts deemed pertinent to this report the appraiser has determined a Fair Market Value as of inspection date, August 27, 1991 FAIR MARKET VALUE: Four Thousand Five Hundred Dollars "as is where is" The Fair Market Value is the opinion of the appraisers and the management of the Automobile Appraisal Association and is arrived at after' careful study of information we deem reliable. However, we assume no responsiblity for errors and or omissions. STATEMENT OF APPRAISAL The undersigned here by states that: 1 . A personal inspection of the vehicle appraised was made . 2. There is no undisclosed interest, either present or con— templated in the future , in the vehicle appraised or the proceeds to be derived therefrom. 3. Neither the employment nor the compensation for this report is contingent upon the value estimated herein . 4 To the best of my Knowledge and belief, the statements in this report are correct and the opinions stated are, based on a full and fair consideration of all the available facts. 5. The findings reported herein will not be revealed to anyone other than the named recipient without permission or until required to do so by due process of 1 aw. After having considered all the relevant factors, it is the opinion of the appraiser that the Fair Market Value of the subject vehicle as of inspection date is Four Thousand Five Hundred Dollars "as is where is" . R4DAID pe lly submitted JA .OB° Executive irector AUTOMOBILE APPRAISAL ASSOCIATIO1 LAW OFFICES OF BORDEN D. WEBB BORDEN D.WEBB 906 G Street,Suite 630 DEBORAH K. PATTERSON Sacramento,California 95814-1813 Attorney at Law Telephone: (916)447-1675 Attorney at Law Certified Specialist in FAX:(916)447-8009 CARLENA L.TAPELLA Estate Planning,Trust and Probate Law Attorney at Law The State Bar of California Board of Legal Specialization SANDRA W. DUFFEY Legal Assistant November 4, 1993 CERTIFIED MAIL--RETURN RECEIPT REQUESTED Contra Costa County Board of Supervisors County Administration Building pie 651 Pine Street, Room 106 Martinez, CA 94553 a`g93 Re: Estate of Ewell David Terry ® SOPtisv�soRs BOp,�LD p QS�PA�O Dear Sir/Madam: cw�oo�cR� Enclosed is an original claim against the Board of Supervisors of Contra Costa County executed by Nancy Lee Thorne, administrator of the above estate, along with.a copy of the Appraisal Report of 1953 GMC prepared by Automobile Appraisal Association. Please file the original, and return a stamped endorsed copy to this office in the enclosed postage prepaid envelope. Thank you for your prompt attention to this matter. V&y truly yours, LAW OFFICES OF BORDEN D. WEBB r, By ebor h K. atterson DKP:jc Enclosures CLAIM 1 1 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT DECEMBER 7 , 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: $379 . 30 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: STATE FARM INSURANCE CLAIM OFFICE ATTORNEY: Date received ADDRESS:P.O. Box 20577 BY DELIVERY TO CLERK ON October 2-8 , 1993 E1 Sobrante , CA 94820 BY MAIL POSTMARKED: Hand Delivered via : Risk Mgmt . I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: oy-wnC 3 . l9q JyIL BeputyLOR, Clerk n� zoo 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: + .1 BY: ��"_Deputy County Counsel -T III. FROM: Clerk of the Board TO: County Counsel (1) County Admi istra r (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. 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:atQ�ar.,1.1�PHIL BATCHELOR, Clerk, By T, , ��,. Q�..=� 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: Acp _9,�_ �j ��j BY: PHIL BATCHELOR by�.��Q, Q�1Deputy Clerk CC: County Counsel "j County Administrator �7 This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or :injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. STATE FARM 4STATE FARM MUTUAL [—]STATE FARM LLOYDS AUTOMOBILE INSURANCE COMPANY INSURANCE ❑STATE FARM FIRE AND CASUALTY COMPANY ❑STATE FARM COUNTY MUTUAL ❑STATE FARM GENERAL INSURANCE-COMPANY INSURANCE COMPANY OF TEXAS DATE OUR INSURED ACCIDENT DATE OUR CLAIM NU BER -18-93 o -0-��3 05-0 &7- q0 YOUR FILE NUMBER YOURS RED nlm� YOUR INSURED'S DDRESS LACCIDENT LOCATION 55 HMD DELIVER U V R�L . * PLEASE REFER TO THE CAP ZONED CLAIM NUMBER WHEN REPLYING OAgent Code: (lam from: Lu Q 1'e, O M S STATE FARM INSURANCE CLAIM OFFICE CL D(n T Po. 60A x0577 > � LLo ` lX'///��' w � X CC „LU -2 a�5 C��ae,l �h ht �l fob/ , , (2a . 4q V 1O ccCD co OU By:z4,6.q EC�r_� Qtm.s S We have been informed that you are the.insurance carrier for the party designated as your insured in the caption of this letter. Our investigation of this accident establishes that your insured was responsible for this accident. Please accept this letter as notice of our subrogation rights under ICS. Vehicle Damage. ❑ Personal Injury Protection (PIP). ❑ Other: ❑ Medical Payments Coverage (MPC). ❑ Should we be called upon to make payment under our policy, we will be looking to you for reimbursement. ® We have made the following payments to date and request reimbursement as shown below:. Net Vehicle Damage Other Name of Our Payee Payment(Less Salvage) PIP/MPC* Payment/Expense* AkAn Lie d ' $ 3x9. 30 $ $ $ $ $ $ $ $ * Please contact State Farm for an updated total of medical expenses prior to settlement.. * * Net Amount PaidInsured Vehicle u ( By Company$ ��' 0 Deductible $ v TOTAL$ � Attachments: G-4379.7 Rev.8-89 Printed in U.S.A. J � ,:til '- ., _.,,�- . :_ _ .•. i•_. - _moi_ ..... :�' ,� �_. .. 1'-.�� 't. - .�i� .^1 :7 - "_� •. - •. .�V. (:. ]I! r .1 ;iP, CLAIM NO 05-0967-190 POLICY NO G224-827-05 LOSS DATE 08/13/93 DRAFT NO 1 02 198091 J PAYEE DATE 08/25/93 MARGARET K RODRIGUEZ AMOUNT $******329.30 555 GARRETSON AVE RODEO CA 94572-1418 COVERAGE TIN COMPREHENSIVE — FLIT, CAC, OR LOW 390-1 $329.30 REMARKS REQUESTED BY Joy Felix •• STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY : 1; 'O2 198091 J NORTHERN CALIFORNIA OFFICE BANK OF AMERICA NT & SA 11-35/1210 + s DATE 08/25/93 91 ROHNERT PARK CA CUSTOMER SERVICE AMERICAS 1233 IM4Y•.MCO HILLTOP AUTQ^ 02-111 CONCORD, CA `f i'� COVERAGE l . ' , * COMPREHENSIVE - FNT, CAC, OR LOW CLAIM NO 05-0967- 190 POLICY NO G224-827-05 CLAIM UNIT 179 "390-1 $329.30 LOSS DATE 08/1-3/93. r INSURED RODRIGUEZ, RAYMOND = Rr r at **EXACTLY THREE%iIUNDREO TLJENTY-NINE AND 30/100 DOLLARS <! ? , !? ' « .Q Pay to the u :k Order of MARGARET K RODRIGUEZ_ 555 GARRETSON AVE'"_�N RODEO CA . 94572-1418 „ TIN aures JFELI APPROVED BY CASH SETTLEMENT AGREEMENT CLAIM NUMBER The undersigned, zz of the City County of State/Province of , hereby ack owledges receipt of the sum of G Dollars, paid by TATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY ❑ STATE FARM INDEMNITY COMPANY ❑ STATE FARM FIRE AND CASUALTY COMPANY ❑ STATE FARM GENERAL INSURANCE COMPANY ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS ❑ STATE FARM LLOYDS on this date, and does hereby acknowledge that said sum is in settlement of amounts due to undersigned under Policy Number S on an account of a loss which ccurred on or about t e � day of (year) at or near The undersigned further acknowledges the Company has explained and disclosed the following: 1. This cash settlement may be considered as prior damage in any subsequent material damage claim if the vehicle remains unrepaired. 2. Any appearance, allowance, or negotiated settlement figure paid by the Company and accepted by ,the undersigned may be something less than the dollar amount which would have been paid providing the damage was repaired. IN WITNESS WHEREOF, undersigned has hereunto set hand(s) and seal this day of , (year) Signed Witness -' J Signed X /;% Address Ji NOTE: For your protection, the law of your state requires the following to appear on this form: Any person who knowingly. and with intent to injure, defraud, or deceive any insurance companv. files a stattmient of claim containing any false, incomplete, or misleading information, may be guilty of a felony and subject to criminal and civil penaltles. California only: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a �rinie and may be subject to fines and confinement in a state prison- Florida only: Violation of this provision is _1 felony of the third degree. 160-4676 a.l Rev.3-92 Printed in U.S.A. J.Michael Walford Contra P:ublic�Works!tDepartment,--,�l-»'�? •---•.. Public Works Costa sn.?ts� �Y s�, - .. Director '�5''Gfacter 15nve�' "�` a�1i11i�094�$�� 7' �` Milton F.Kubicek County FAX: (510)313-2333 Deputy Director Telephone: (510) 313-2000 Maurice E.Mitchell Deputy Director Our File-Chip Seal Work Notice Dear Resident: We are go' g to o some surface treatment on the street in front of your home and several adjacent streets in your area on .3 (In case of unseasonal rain, we will begin work on the first non-rainy day following the above mentioried date.) We wish to call to your attention the following precautions to help us perform a better job and protect you, your family, and your property. Please park your vehicles off the street to avoid oil spray or other complications. The streets in your area will be closed to through traffic during the time the actual resurfacing work is in.progress. We will need the full street area between 7:30 a.m. and 5:30 p.m. Your cooperation will make it possible for us to give you a better job with a minimum of inconvenience to you. Vehicles parked on the street on the day of the chip seal operation will be towed. ... Keep your children and pets away.from the.street while we are doing the treatment. Several large pieces of equipment are involved. ... Drive slowly,the pavement can.,be slippery.because of the.loose.rock: If you find it necessary that you leave your house or have someone visit you while the work is in progress on the street in front of your house, please drive either on the portion of th`e street•that has been chipped or the portion that has not been covered with the asphalt. The loose rock will be swept up in.about 7 days. ... Warn your children to.be careful while riding their bicycles. It would be:preferable if they refrained from riding altogether until the loose rock is swept up. ... Check the bottoms of yours and.your children's shoes before walkingjnto:Your house. Until the pavement is swept, the chips can be 'picked up and tracked onto carpets or'scratch=wood floors. Continue to park your car off the road or cover it until the initial sweeping:is.completed. Loose rock throvrn up by speeding vehicles could damage.your car's..paint. We realize what an inconvenience this treatment is to residents, ,but:.the:.:.alternative of doing nothing will result in accelerated pavement deterioration requiring very expensive pavement°overlays.and reconstruction. much earlier. Such an option is not cost effective nor feasible within':the County.Public Works Budget. We thank you for your cooperation. Please give us a call at 313-7000 if you have any questions. Also call if there are any problems after we have swept; we will inspect the street and resolve any problems as quickly as possible. Very truly yours, �;!:�. Jct. ��2 C..C.v.`�• -� Gre Connaugh A ing Assistant Public Works Director Maintenance Division PMC/pc chipnot � , � '�5 y�' at l ^ : �� File A1O186-0006l70 E1 Cr ` . � �� (� 'T* E.'-: F' (l Ri~1 I PA wi ij [Q fl 11-1 [, E� [' C) 1-1F" �i 1-1 T E � LIKE A CUUD NE [GHO0k . STATE FARM IS THERE CE Q- o <Z 2920 H [LLT0P MALL ROAD � a,U) Cr LL. RICHMOND , CA 9=6 ' (L uj ( 510 ) 262-4900 TZ U'<u ESTIMATE OF RECORD t cc 0 Z � Written By ; F . UNDERHILL # 08/25/93 1206 < Lu u- z <nsured : RAYMOND RODRICUEZ Claim #05 O967 190 B "� _ _ �< Claim Rep : - 1: Address : 555 CARRETSON AVE < ' RODEO , CA 94572-1418 Date of Loss; 8/13/93 Day : ( 510 ) 245-7308- Type of Loss: COMPREHENSIVE 101 Other ' ( 510 ) 245-7308- Point OF Impact : 16 Non-Collision Inspect ` Location, HTSC `` , 94572�1418 D . ioe-In � m R oc epair o F- CC � ' Q.� � 17 FORD AEROSTAR 4%2 WAGON 2D VON @LUEN Cr � IM : 1FMCA11U9HZA99521 Lic . #: 2EKU578CA Prod . Date: O/0 �� Mileage: 76908 00 uj] ` o � ------�---------_---`--------------------�-_--_--_----_ �_--�--__----��-�-- �----- z �z< ' _ - - ` < uuPR/REF PARTS LBR ' PAINT t0 � . � ' | REPLACE DESCRIPTION OF DAMAGE QTY COST -HRS ' HRS ' ' MISC a.+ / ' ` u.v,--- ----T------�--------------------_�-------------------_---_-----------"�-�---- � ��<1* Repair CLEAN SHEETMETAL OF OIL SPRAY 1 0 . 00 - 4_,0 0 . 0 � � ' . � _._^ � ��2* ' OLEAM CLASS OF SPRAY lit 0 0� ___�_�� 0 0 ! � ' ' '---��'�� REWAX VECHI[LE / . 1 0 . 00 __]^^_; 0 . 0 ' ----- ---------------------------------------........-..... ............__---- Subtotals ===> 0 . 00 7 . 0 0 . 0 40 . 00 | v 0� <Lj ma. Cr CL F- 0 <Z | � CE LLJ / E CL LLJ LLJ tr � � � LLJ o � cc < Z z< < mu- � ^� z < mz« � �K�3 �~�U _j I... ..I.. t 1- 1::- 1:7 f:.* V I < E, 1_1 F" t:) 1-1 J, 0> Er� F- Zt Cl W it P L.LJ E (I L z 00 Uj Cr LU W CC cr O 0< LU-j Cc 0 Cr Z Z< U_ LU C) UJ�- z _J< a-�_ Ln a-Lo LO < (n :F >- _j CO ..D Uj Q o� . Ff UJ r a. U J t., uj,;, CL N.a:. X"Lu'':j 0 < <AU U_ F'.. LU 0,LuH. < F- Cn Q. Labor 7 . 0 If r 48 . 00/Fir 336 . 00 5 11 b I e t/M i c. 40 . 00 3. SUBTOTAL 5 376 . 00. D;` T a x nn 40 . 00 at- 6 . 2,500% 3 . 30 I`QTAL , COST OF REPAIRS 379 30 <LU W)JUST'llEllT-S S . Ir - .R6> D e cl tt c t 1 b I e -.50 CIO UJ < 0Cr n!nporary Repairs 0 . 00 T-OTAL ADJUSTMENT'S 50 . 00 Z_ 23i6r/Unrelateil Darnage 0 . 00 NET,. COST CIF REPRIRS 329 3 0 F C) Fr cr < w¢ x 0 < i Lu0_j cro Estimate based on MOTOR CRASH ESTIMATING GUIDE. Mon-asterisk(o) items are derived from the Guide DR2MLB6. Database Date 0/0 :DgIZE5t A product of CCC Information Services Inc. < (n � rr Z Z < W U_ 0 z a._j< P a q c.-_' Z_ NQ _j CO lid STATE FARM WI01 STATE FARM MUTUAL [:]STATE FARM LLOYDS AUTOMOBILE INSURANCE COMPANY INSURANCE ❑STATE FARM FIRE AND CASUALTY COMPANY ❑STATE FARM COUNTY MUTUAL ❑STATE FARM GENERAL INSURANCE COMPANY INSURANCE COMPANY OF TEXAS DATE 0 INSUR D ACCIDENT DATE OUR CLAIM NUMBER* iv-�8-q3 ahja uLz rl S -a - 7 5- c � 7 YOUR FILE NUMBER YOUR INSURE U Ks YOUR INSURED'S DDRESS ACCIDENT LO ATION a5 5 >✓L �5�3 X55 Q on CSA. NAND DELIVERED V 6k' Ie L,-k)'nr l * PLEASE REFER TO THE CAPTIONED CLAIM 0a- NUMBER WHEN R PLYIN Q ® N Agent Code: / N From: > ' . , 1 STATE FARM INSURANCE CLAIM OFFICE LU LU Yab*/NO i G vVbh I�s �.�h��,►�� p p ,doh 205 '7'7 00 C) I N �CC W o 0z o (1,©cc UJI Y JU U We have been informed that you are the insurance carrier for the party designated as your insured in the caption of this letter. Our investigation of this accident establishes that your insured was responsible for this accident. ® Please accept this letter as notice of our subrogation rights under I,L�I Vehicle Damage. ❑ Personal Injury Protection (PIP). ❑ Other: ❑ Medical Payments Coverage (MPC). ❑ Should we be called upon to make payment under our policy, we will be looking to you for reimbursement. ® We have made the following payments to date.and request reimbursement as shown below: Net Vehicle Damage Other Name of Our Payee Payment(Less Salvage) PIP/MPC* Payment/Expense* Iffia0m $ 3 . 30 $ $ $ $ $ $ $ $ * Please contact State Farm for an updated total of medical expenses prior to settlement. * * Net Amount PaidInsured Vehicle By Company $ - 2�� 0 Deductible $ `,v ' � TOTAL$ Attachments: G-4379.7 Rev.8-89 Printed in U.S.A. - '"l`;_c 1', .A— _... .if':.: ,..':i gid'. ..- ._ ,,�• ', - 1� ^t.}(`.. -:.r._i .�li Zl,l�'i. il •�� ..' 171.. _ -nt•,• ':�1 F . ._.? �._ _.- ice' -r_ X3:.1 Q .�_+ .. C.•v.�.W''_ .i .1..IV pp,, Y iVrJ 3I S �'�� CLAIM NO 05-0967-191 POLICY NO G258-389-05A LOSS DATE 08/24/93 DRAFT NO 1 02 198093 J PAYEE DATE 08/25/93 MARGARET K RODRIGUEZ AMOUNT $******3 2 9. 3 0 555 GARRETSON AVE RODEO CA 94572-1418 COVERAGE TIN ti COMPREHENSIVE - FWT, CAC, OR LOMV 390-1 $329.30 REMARKS ;A REQUESTED BY Joy Felix N STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 `0Z 198093 J NORTHERN CALIFORNIA OFFICE BANK OF AMERICA NT & SA 11-35/1210 ROHNERT PARK, CA CUSTOMER SERVICE AMERICAS 1233 ;; DATE 08/25/93 HILLTOP AUTO 02-111 CONCORD, CA 7 COVERAGE COMPREHENSIVE - FWT, CAC, OR LOMV CLAIM NO 05-0967-191 POLICY NO G258-389-05ACLAIM UNIT 179 390-1 $329.30 LOSS DATE 08/24/§3 f a' a� l} INSURED RODRIGUEZ, RAYMOND ***************************************t*************EXACTLY THREE~HUNDRED TWENTY-NINE AND 30/100 DOLLARS <! ? 'X Pay to the Order of MARGARET K RODRIGUEZ 555 GARRETSON AVE�� RODEO CA 94572-1418 TIN AUTH JFELI APPROVED BY I 110 U0P n . t . 1. y Pr':' , Fn Q NH L k , O w 7 CLQ E' L .tl"11.lf li_t Lilt; a no- LU 1.5 i r Cr Uj Written ` 00125 07 P mw W J Q :. n a !s•:.i-1, r:..r; . 1:'t-t'It'1!1fIl.J �...1Df; I:G'•..!E.::_ Q CO 94571- 1401 Do `:e of Loss , S. .' /O_`. Dau f .. 1 0 1 45 r.. .. '. Type is Lov5 : _,UI.P . HE..NS 1 E F ... - ' _ .. _ _ ' ttr.Ft ,l:� : � ", IUI �:}i_,:_ , .ti'�a F',•i 'Ir�+ t: (i !' lrn(,:1 '- � r'i�'itt .,: I I 't _ 't ,..,n ,. .,..i Ei e:....; t +,l.., L <W Q O? ,. 4 — Ir Z OW D ¢a - a l_fl'r'O .4PUMhIE::E; 4X4 SR5 40 I-iTr.l Cft'EE::I''i S Q i t1 J1...31.tt''139=01. 1. 0:x :;_' E-. r C: A . 5DE8524 CA Prod . Date , it J Mileage : Oa = W� - Cr C ut z z a ._... .. . -....._ _..._._......... ....._........._ ._ . . _ ...... ... .:. Z) at� ;I*i =1L( CEiESCRE ' ClE ` OF DAMAGE C7Y COST HEHRS mi z . n - _._. .. -_.._ -_.... - ---._.... -- _. .. -_. - -_.. ..--- -. _..-_- _..--- - -.._. ...-_..__ -__.. ... ... ... ...._ _.... - ... ......... -.- - -._. -- - ...._......... n U Q (,,:.:, CLEAN ';H E E:. F.r„I�_.T.A I ,, f SPRAY 1 i't I i t In rt t r' i L 1 i I ;'I OIL F{r i'( e - J - co CLEAN CLASSOF SPRAY !. i) 0 't J _•4 ��l7 1 < ow ) LU LLJ ui C- IJ cr E 5L C, 0< LL, Cr Z Z< < LLJ LL 2 LU (D W� z CL-j< CL Cf) U)< CO 00300 CL < 0 LL) 0- cr a_ Ir 0- C) <Z Lr0 W z Ow CL w < LLJ CC cr LU m < CC Z Z< < LIJ LL C) Z < CL�— 0 U) < T _j>- CC ................ ...... 0 . ....... ... ... - jj < n> o "I T, -'tuft 1zr cr CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT DECEMBER 7 , 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: $10,000,000 .00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: THREDE,Kathryn S . , Guardian Ad Litem for Minor, THREDE,Nick A. ATTORNEY: Date received ADDRESS: 913 Halite Way BY DELIVERY TO CLERK ON October 28 , 1993 Antioch, CA 94509 BY MAIL POSTMARKED: Hand Delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. eHIL BATCHELOR, Clerk DATED: FYJ� �xe�. .� l cJ q 81�: Deputy 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: "f/(y-vr .1�u 3 , ��3 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 (v-J' 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 ,,, 7,1g53 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. p �n1nn Dated: 11,93 BY: PHIL BATCHELOR by � �SClL�_ Deputy Clerk CC: County Counsel County Administrator r This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above dist is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. 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 945533- 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 KATHRYN S. THREDE, ) Reserved for Clerk's filing stamp Guardian Ad Litem for minor, ) NICK A. THREDE, ) RECEIVED VS . ) COUNTY OF CONTRA COSTA, ) Against the County of Contra Costa ) OCT 2 819M or JUVENILE DIVISION, and DOES ) 1-100, inclusive, CLERK BOARD OF SUPERVISORS District) CONTRA COSTA CO. Fill in name HAND DFLIVUEf �' o The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 10 , 000 , 000 . 00 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When dial the damage or injury occur? (Give exact date and hour) On or about June 12 , 1993 at approximately 8 : 00 p.m. [NOTE: Sheriff' s report attached is inaccurate as to the date of occurrence. ] ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) Contra Costa County Byron Boys Ranch, Byron, Contra Costa County ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) Plaintiff, Nick A. Threde, was held captive by another prisoner while in a laundry closet doing chores and was sodomized by said prisioner who has since been convicted of said crime and is sentenced to 8 years in the California Youth Authority for said crime. ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Due to the willful and continued negligence, lack of supervision and total disregard for the physical well- being of Plaintiff, Defendants named herein and to be named at such time as their names become available, allowed continual sexual harassment of Plaintiff to occur and caused and allowed pornographic movies to be seen at the Byron Boys Ranch by prisoners and counselors on at least one occasion, 6/12/93 . � `��I ��a s��'U�. �,� � �.. 5. What are the names of county or district officers, servants or employees causing the damage or injury? Orin Allen, Superintendent of the Byron Boys Ranch; �_ . Eric Brown, Counselor at Byron Boys Ranch; Counselor in Charge on the evening of June 12 , 1993; and any and all other responsibile parties. - ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or, damages claimed. Attach two estimates for auto damage. Nick has suffered and continues to suffer from severe emotional distress and low self-esteem. Nick has and continues to be sexually harrassed by former prisoners and tiths��.uy Lil hQ hs3Y�_11€��5� abouts� tt�he _incident on 6112//93. In the future codthuoetntfc�'ammec above computed?er(Isncu� ie ima ouansof any prospective injury or damage.) It was computed by the physical and emotional stress this incident has caused Nick; causing him to require and may continue to require psychological counseling and self-esteem counseling; __--,-�S _well as possible future medical attention for perhaps the rest of his 11J----------------------------------------------------------------------------- 8. Names and addresses 'of witnesses, doctors and hospitals. Fahim, Counselor at Byron Boys Ranch; Orin Allen, Supt. Byron. Boys Ranch; Eric Brown, Counselor Byron Boys Ranch; Bixler Road & Byers Road, Byron, CA; Roger LaFleur, Probation Officer, 300 L Street, Antioch, CA. . 94509; .Kaiser Foundation, Bernard Schatz, Phd. , 200 Muir Drive, Martinez , CA 94553 . ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Numerous Use of Kaiser Foundation counseling services and counseling dates through REACH Project. Travel to and from each. Exact mileage is unknown. 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 In Pro Per KATHRYN S. THREDE, Guardian Ad Claimant's Signature Litem for minor, Nick A. Threde 913 Halite Way 913 Halite Way Address Antioch, CA 94509 Antioch, CA 94509 Telephone No. (510) 706-2113 Telephone No. (510) 706-2113 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. ■Face Poge CONTRA COSTA COUNTY SHERIFFS DEPARTMENT CA0070000 Brest � 0Co,rammtiDn P.O.Box 391,Martinez.California 94553-0039 0 supowner at ❑MRO ❑Arrest ■S+ 1.DR No, 2.City Coda 3.Crime/Clawrrcatton 4,Detail 1 5,More 93.14 0 itQ 50 1 D 0 m Y . 2. Pwsol^s 6.0 /Dale/Time of Occwrane 7.Date/Time Raportad 8.Employ**No. 0 A./'. •1 /� 3/ Z S.Raclassi- t0.Addr /Loudon of OccunMicaeo� ca � - � � . . tl, 0 PRI E3 WIT OMSP ❑RUN 0 SUS LEAD [)Other 12.Name(L.F.M) 13.Race/Sex/Ape 1a.DOB 15.Onvar License No. 16.Address (Zip Code), 17.Homs Phone Is. q4qj SIX,,eg 8ygQJ0 Ernp&gyod By hoot 19.Work Phone . 4414P 20.Nair 21.Eyes 22.Ht 23.Wt 24.AKA/Maioen Name 25.Sotaal Seewrty No. X FurtMr Ol scripbon{Sears.Tattoos.Mannerisms,Clothing.Etc.) 27.Booking or Gte No. 28. ©PR) ®VIC p WIT IJMSP RUN ❑sus LEAD Other 29 Name(L.F,M) 30.Race/Sax/Ape 31.DOB W.Drmw License No. /C i -Z - 33.Address (Zip Code) N.Home P/wna /3 N t ) 7CYr Z&3 35.Empioyw By or School 3&.Work Phone 3Z Hair 38.Eyes 39.Hl 40.�WL•- 41.AKA/Maiden Name i ` � 42.;,ocw1 aacurir hic. . 43 Further Description(Scars,Tattoos,Mannerisms.Clothing,Etc.) u.Booking or Dile No. 45 PRI [')VIC O WIT O MSP ❑RUN SUS [-j LEAD ❑Other 46 Name IL.F M 47.Race/Sex/Age 48.DOB 49.Driver License No. $0.Address Z 0 Godo) 51.Home Pfbne ME* 1 1 :.2.Empl 13y-or School 53.Work Phone ,a - - Z, ( ) A.hair 55.Eyes 56.Mt. 57.WL 58.AKA/Maiden Name 59.Social Security No. M 60 Further Description(Scars,Tattoos,Mannerisms.Clothing.Etc.) 61 Booking or Cite No, 52 Veh/Vas 63.Lic.No.(State] 64.Year Make 66.Model 67.Body Style 63.Color Tip S o Vict -7 Bottom 39 Status 70.Registered Owner 71.R.D.Address ❑Leh Impound 72.Towed to or Released to 73 Who has keys? Stored d End. Yes 75.f/P O Yes 76.Dispo of En)oence 77.S Missing 78.S Damaged 758nef Synopses of incident (21 1} N /� J 4 /mml/og- la) (.1 (6i +71 / 60 D,stribu+on B1.Additional Pouting pB ❑C 00 DE ❑L `)0 SR ❑V Invenigahon e Vice ❑Narcatcs ❑Coroner B2. aporing OeAuty(Pr t) 83 Dale/Time Nn nen 84, neo operty CIL i CS (]Intel{. O R.O. SHC77 P trot plain Compl 01c. Marine a rot B5.Appro�Dq Pv(Pri 86 Supv No 87, ate 88 P her n 1 Cdr FO (Rev.1/89) , Continuation CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT CA0070000 Beet , Dsupplemental P.O. Box 391,Martinez,California 94553-0039 D HRO D Arrest ■sl 1.DR No 2.City Code 3.CrlmerClessilication 4.Deter) 5.Racists;_ 3- I Sa 2 6caton .. 6 Vrcbm:jam*(L,F.M) 7.Date Ovig.Report B.Employee No. 9.Address/Location of Occurrence 10.Suspect's Name(L.F.M) 11.Property Dascnpuon: Impounded.Recovered Found.LosL Stolen-Item Number.Article.Ouanhry.Brand I Make/Manutacturer's Model Number.Serial Number.Misoetlaneous Description.Location Where Taken,Value.Include Total Loss-LIST IN FOLLO,NING ORDER:AI Currency,Notes:B)Jewelry;C)Clothing.Furs;D)Vehicles;E)011ice Equipment F)Radio.TV&ati" G)Fnearms:H)Household Goods:1)Misc. 12.Recovered Property S 13.Narrative r Statements (1) (2t /+tiI (4 rs t5) ♦ //L1 16; /UO D u i2 . . .., (7) (8)"kl 49) (10) . '0 w Av'PA"eo 504com o mv 4,exlz- OR/Iv E N O T1/•9T ♦S S AD CONDUCT „2)4 9007-1AJ S01594'C OF77VE A (13) VeMyr,161J c Co.jN / aAjo .s A� USED d0 DbrrL C E ,h4VCVIL DAJ (151 A D E L n6) X10 &=ZrAJ &-P0-M-1Ze0 (17)1-/94AJne ♦p ♦im"r- ey S-ftwwc ORIN, 1296F6n VAJCD.. , LRREPE. zkgep A oo,og vs A DWI& 54♦ 120) -KI-4 e7- YPA ree4l" o .e.S C /lA;4 V,04 4 iE4aXQr': (21) O / D '-5V00,"/Z,6 /M (22) L O O ♦ DID /VD lvAAu (23, /r». D E 1519/ W 5 F u (24)/J" A67 DIP ♦ E A-16- Out-D 436 �2 (25) E / 0 /E N 06^'1 PRIOR D 14 Di3lritwLOn 15.Additional Routing - ❑B ❑C [1DA ODE ❑L ❑O []SR. ❑V [(Investigation . ❑Vice ❑Narcotics ❑Juv ❑Coroner Prop"Ck D ACS D smell Q R.O. [-)SWC 16 Reporbng Depu (P 17.Dale r Time Warren le ispo. O Petrol Captain []Comp.Otc. C)Manna Patrol Jos,IN `� — G/4D /)C� Other 19.Approving Supv.(Print) 20 SUP+.No 21.Date 22.Page �rn FORM B (Rev.1189) ! ,ate,'.3 ' =Gct nue9f>n CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT CA0070000 2 P.O. Box 391.Martinez,California 94553-0039 p HRO . OA"st ■S' (J iiupplamensa+ 1.Dabrf t. S Reclassi• Csty Code 3.CrimerClassification 2 ticasan 3-1 b l'7 po la T.Date060a$aorf a Employee No. e V.cvm`wTo M1,V.MI (L.F.M) .. 9.Address/Location of Oacurrenoe 10.Suspeas Name = ' tl.Property Descnpt,on: . Impounded.Recovered Found.Lost,Stolen-pem Number.Article.Ouanlity.Brand f Make/Manufacturer's Model Pknnber,Serial Number.Mlscelleneoua DesGtptttm Location Where Taken,Value.Include Total Loss-LIST IN FOLLOWING OAOEFt A)Currency-NWes;8)Jevreltl:Ci GiolRmg.Furl.Di ltet clw Q Office Egruptnettt F1 Radio.TVs.eft.. Csi Fitea�ma:'I't)Nousehoi0 toocts:t)MisG.. �//y�'�/{ 12,Aoowlrod Propefty s SsatemeRts Il a�fr/ r, tEN L (2) r (3r d AMMMO (4) (si rIf V- �� AW $, ttd} (13) (14) (15) (17) (20) (21) (22) (23) (24) (2s3 14.D,sitioullon 15-Addiliorlal Routing QB ❑C ODA DOE ❑L []O 0 S OV Fl Inves4ption O Vice ❑NWCObc9 ❑Juv O Coroner O property Ck. Q ACS ❑lrnaii. ❑FtO. Q SNC 16. porang Depute(Pn f7.Date/Time vWieen I t Oispo. []Patro!Captain ❑Comps ox. ❑Merwte Paco+ AJ G 1 — OP^t?0J 19.Approvrng Supe IPnttt) 20,Supt.No, 21.Dab 22.Page of FORM 8 (Rev.t lig) .F..... �......��.......�.,�wwwpr•�t,�'.n.�^s- "_`7 F .'..p..a,.�r^f'Tr'CJ-p'.�.'.a...w-+.�{ye••-'*w-L"i'4. � r' y .. .. t ✓1• t_ a ..F L i 7 w``."^'.,...S r'a+ ✓,.� +vt r$ •,.ren ,W.,c ..ice'.+ J.r war+r,... ^ w...�x::-:c;:,...^"..,!.: ..Y.•'✓,'..�,' ;�w st'e�i' ....r..,.;._�.. cRIME�IJdLVS°fS SURALEEIElYT GVIs7"RA GOOT/►G_ouliTY M1f1cnitrF1e OFpArtTMENT CA0070000 1NMENT PAGE P.O. Box 391;Martinez,California 94553-0039 1 OR No 2.Crime/Clasa lication 3 Oab,il code.i. '� •. 2. N F elony ❑M isd" ❑Arrest ❑Cho 5 Viet.m"lame JL.F) 6.Address/Location of Occurrence T.Employee No. S.Gang Activity ❑Yes ❑NO OP ❑ Other Prints LEGHO ❑ leg Holster TRK ❑ Truclting COMO" PS ❑ Paint Samples PISWP ❑ Pistol Whipped TV5 ❑ TV/Stereo Pales/Repalk 9.Name of Gang PH ❑ Photos PURSE ❑ Purse WHS ❑ Warehouse //�� ) PJ ❑ ProfacriI*/casing RERPK 0 Rear Pocket OTH a Other -..ar�f:Jjci� 10 MEANS OF ATTACK RK [] Rape Kit RIGHH ❑ Right Hand e ❑ Some ST ❑ Semen PSACK ❑ Saek/Bag 21.sUsPECTs ACT/Olrils C 0 Club/S`tick SP ❑ Shoe Prints SHOTS ❑ Shots Fired APPFF ❑ Approach from Front F Ci Firearm SK ❑ Sketches SHLHO ❑ Shoulder Holster APPFR ❑ Approach from Roar G ❑ Handgun TT ❑ Tire Castings WAIST ❑ Waistband ATEOR ❑ Atelorank K L] Knife TL ❑ Tool Marks BLIND ❑ Blindfolded VicAm . N Martial Arts Weapon VH ❑ Vehicle 10.CIRCUMSTANCES BOGAG ❑ BounO10"ga,d P ❑ Physical(Hands) WP ❑ Weapon R ❑ Racial/RN[gious/Ethnic CIDVVF ❑ Covered Victirs'1s Foos R ❑ Rifle/Shotgun t9 ALARM DEFEC ❑ Defecated S ❑ Shoes/Feel 13.METHOD OF ENTRY N ❑ None DEMON ❑ Demanded Money T ❑ Threats A ❑ Attempt A ❑ Activated DISAL ❑ Disabled Alarm V ❑ Vehicle D ❑ Bodily Force p ❑ Bypassed DISPH ❑ Disabled Phone O ❑ Other G ❑ Bolt Cutters/Saw 0 ❑ Disabled DISPO ❑ Disabled Power E ❑.Common Ceiling/Wall DISRO ❑ Dtsrobed Victim 11 PROPERTY ATTACKED •- L ❑ Cut 20.WHERE OCCURRED - FIRED ❑ Fred Weipon ARG ❑ Agnculture C [} Hid in Building APO ❑ Apartmerd/Condo FOLVM ❑ Fottowed Victim ANT ❑ Antiques O ❑ Lockbox APT ❑ Auto/Tire Slores FVMTM ❑ Forced Victim to Move ART ❑ Ari/Paintings - B ❑ NSFE BNK ❑ Bank/Savings A Loan FD1SR ❑ Fully Disrobed(Suspect, AUT ❑ Auto Parts F ❑ Pry BAR ❑ Bar/Lounge/Tavern HBD ❑ Had Been Drinking BYC ❑ Bicycles 1 ❑,Slim Jim/Coal Manger CAB ❑ Cab/Taxi HITCH ❑ Ndchniking 507 ❑ Boats H ❑ Smash/Break/Punch ,CWA ❑ Car Wash - IMPOT ❑-Impersonated Other BLM ❑ Building Materials K ❑ Unlocked CHU ❑ Church INJIN ❑ inflicted Injury CAM ❑ Cameras I Projectors CLN ❑ Cleaners JUMPC 0 Jumped Counter CLO ❑ Clothing 14.POINT OF ENTRY CLO ❑ Clothing Store KLOCA ❑ Know Location of Cash CRC Cl Credit/ATM Cards Window Entry COC ❑ Construction Company LCRET 0 Lifted Cash Register Tray CUR ❑ Currency WC❑ Crank COS ❑ Construction Site MADPR ❑ Made Purchase . NQC ❑ Drugs WD❑ Louvered CON ❑ Convenience Store MTHRT ❑ Made Threats FIR ❑ Firearms WA ❑ Nonmovable - DPT ❑ Oepamnenl Store MASTU ❑ Masturbated FRN f 7 Furniture WB❑ Sliding MDO ❑ Doctor/Dentist Deice MOLES .❑ Molested Victim APP ❑ Household Appliances Door Entry DRG [] Drug Store MULTI ❑ Multiple suspects IND ❑ Industrial Equipment DG ❑ Double Swing DWY ❑ Driveway OCCUP ❑ Occupied Building JEW ❑ Jewelry Or ❑ Garage(overheadl 2P ❑ Duplex/Fourplex OFVFD p Offered Victim FoodlDrfnk LIO ❑ Liquor. DF ❑ Single Swing FFS ❑ Fast Food OFVRA ❑ Offered Victim Ride LN ❑ livestock DH ❑ Sliding GAD ❑ Garage Detached OFVS ❑ Offered Victim Sex MED ❑ Medical Equipment DJ ❑ Other GAS ❑ Gas Station ORALC ❑ Orel Copulation Iriv. MIS ❑ miscellaneous Other Entry GVT ❑ Government Facility PDISR ❑ Partially Disrobed(Suspo" MOT Motorcycles/Minibikes OF, ❑ Basement SMS [.) Grocery-Small Store PKLOT ❑ Parking lot MUS ❑ Musical Instruments OK ❑ Floor MKT L Grocery-Supermarket PRPEX ❑ Prepared Exit ' OFE [] Ofri,ce Equipment 00 ❑ Ground Levef HWY ❑ Highway/Sheet/Road PPPAG ❑ Put Property in Bag PUR ❑ Purses/Wallets ON [] On Premises HOS [] Hospital RAMS ❑ Ransacked RAD ❑ Radio/Stereo - OL L3 Roof HTO [] Hotel/Mosel Office - RIPCL E] RtoPed Clothing COL L]'Rare Coins OR L) upper Level HTR L].Hotel/Motet Room SELEC ❑ Seteclive in Loa SLV ❑ Silverware OM E Wall JEW [] Jewelry store. SMOKE [] Smoked on premises, SPD [] Sporting Goods 00 U Unknown LAU ❑ Laundromat SARM ❑ SuspeclAril TEL [] Television/VCRs UO ❑ Liquor Store THRET ❑ Threatened Retaliation TOR [] Tobacco Products t5-ENTRY LOCATION MAL ❑ Mail TCONC ❑ Took Concealables TOL, ❑ Toots F [? Front MFG ❑ Manufacturing Firm TDRUG ❑ Took Drugs/Narcotics VEH ❑ Vehicles(except motorcycles) R ❑ Rear MAR ❑ Marl Dock/Waterfront TSTTV ❑ Took TV/SfereoOnly S ❑ Side MOV ❑ Mpvielplaynouse TVMCL ❑.Took V,clim's Clothes 12 PHYSICAL EVIDENCE O ❑ Other SKS L] Office Supply/Book/Stationery UID [] Under influence Drugs AC ❑ Accelerants OIL j 1 Oit Company UNOCC ❑ Unoccupied Building AL ❑ Alcohol 16 NUMBER SUSPECTS �' PPK [ ] Park/Playground ODORS Li Unusual Odors BL ❑ Blood LOT L.] Parking Lot UDEMN ❑ Used Demand Note CL ❑ Clothing 17,HOW WEAPON WAS USED RAL ❑ Railroad ULOOR ❑ Used Lookout DC ❑ Documents COATP ❑ Coal Pocket RAP ❑ Rapid Transit/BART MATCH ❑ Used Matches DR [,; Drugs COVER 0 Covered RES ❑ Resrdentral House USVEH ❑ Used Stolen Vehicle FP (� Fingerprints PROPK LJ Front Pocket RST ❑ Restaurant UVNAM ❑ Usk Victim'sName GL �_; Glass Fragments PANPK (J Mand m Pocket SAL ❑ Salvage/Wrecking Yard UVTOO ❑ Used Vretims Tools HA U Hail HIPHO Hip Holster SCH ❑ School VANDL ❑ Vandalized MS _ MUdtSoil LEFTH L, left Hand SPT [, Spor ng Goods Store VEHND ❑ Vehicle Needed 22,Disvibuhon 23 Additional Routing. i•�B r!C C30A ❑DE [_]L []O ❑SA ❑V L]investigation []Vice ❑Narcotics L—.Juv i�Coroner 24, ponmq beputy Prm 25.Date/Tim.Wrrlten 26 D posit-on L.J Property Ck. ❑ACS L j Irrtell. i R 0 L SHC s 1- PA1,01 Caplain []Carl OIC Marine Patrol 27 Approving Sl(Ptinti 2B Supv No • 29.Deis 30"P Other MRM C Inrn PiAli