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HomeMy WebLinkAboutMINUTES - 10221996 - C14 CLAIM BOARD OF SUPERVISORS OF CONTR4 COSTA COUNTY, CALIFORNIA October 22, 1996 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Boar 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 642.59 (Paragraph IV below). given pursuant to Government Code Amount: Section 913 and 915.4. Please note a "INUVIOD CLAIMANT: Mr. & Mrs. Ala Ammsso OCT 10 1996 ATTORNEY: owwry COUNSEL Date received MARTINEZCAUF. ADDRESS: 1112 Williams Hercules, CA 94547 BY DELIVERY TO CLERK ON October 9, 1996 BY MAIL POSTMARKED: Hand Delivered; via Risk Mpmt. I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted claim. DATED: October 10, 1996 `VIL JeATTCeELOR, ClerPUTy k���, II. FROM: County Counsel TO: Clerk of the Board of Supervisors 00 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: BY: (�(/'�t$w V 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 (x) 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. Q Dated:ia- z'z -gCy PHIL BATCHELOR, Clerk, 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. 4 Dated: /0—Z!5_- /'19(P BY: PHIL BATCHELOR Deputy Clerk CC: County Cc.:,.se-: County Administrator Calc tot WARD OF SUPERVISORS OF COMM 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 chich 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 per=nl property or growing crops and 'tbich accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause Of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of. action. (Govt. Code 5911.2.) B. Claims must be filed with the Qerk 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 nave of the District should be filled in. B., 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 Ser. 72 at the end of this fom. BE: Claim By ) Reserved for Clerk's filing stamp ) IRECEIVED Against the County of Contra Costa 9 I or )District) RO OF 5U Rv►SORS jUMM COSTA CO. Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-naaeed District in the sum of $ and in support of this claim represents as follows: a►;Lits ncltFl {�,� V-71'- d-t&e & G1 L'- -r• - - 1. When did the damage or injury occur? -(Give exact date and hour) act(0 2.M._ d_id the dama ? w in jti .ems^ (Include city and county) c �h.V4 AJ pht.O L A'. J 3. How did theCdamage or-� occur? (Give full. details; use extra paper if required) /+S cCi4v;V 0-^ ✓aVurR"cA kc.?a.d, ► �' ^ems �►, i b►oton e� lk-I ra"Ast air tU ot*jnr V�eua pt-Gte �, b,�lu.,, pc►w� , t[ ro ,-� 9k.,zrp e44 a—d yq_v - c- ¢ aid L, i¢c a—W, �zn r .t�..F 6t r'd-epwapd. + toc&&d 0.?�nu /ivm to; 74s prr a& u. What particular act or omission on the part �Of county or district officers, se-rvants or employees caused the injury or damage? rftp,tl,,,c:a /1�.,�C c o (,{, ����� C e,� - L- -►� 'frcAue Gc ,�t1tv.1� �� 7&UV r,l Ctk •f ro gl)'_ � 0� t9 K C rid ct,�. PaN-�'-,3 6� -ttw, /L4)&d 6a,,Ge� tl z road j. wnat; are the names of counzv or district o'fieers, servants or employees causing the to=; ae or injury? 5. What damage or injuries do you claim resulted? (Give Hill extent of injuries or damages)claimed. Attach two estimates for auto damage. ,t- 64--21 da..<:1.0 CcTr' + f,, r4x cfro At S�+aW,,, �.,�� %L✓a err �+o+w--� ZX2Z.. , 4:5f(S- -SY 642 Sq 7. How was the amount claimed above computed? (Include the estimated amount 'of any prospective injury or damage.) $.. Names and addresses of witnesses, doctors and hospitals. 9• List the expenditures you made on account of this accident or injury: DATE ITEC , Maw Gov. Code Sec. 910:2 provides: elaim must be signed by the claimant SbW NOTICES TO: (Attorney)* b some on his behalf.TM Name and Address of Attorney Mr. VMrr. Ala Awmsso Claimants Signature Address, CA .. q 4gq- -' Telephone No. Telephone No. '72.6-4 �1 NOTICE Section 72 of the Penal Code provides:, "Every person who, with intent to defraud, presents for allowance or for paym nt 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 sueh i-risa~uaen., and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA October 22, 1996 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements. ) NOTICE TO CLAIMANT and Boar: 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_ allwalavM . CLAIMANT: Richie C. Campbell OCT 10 1996 ATTORNEY: Date received CARTINEZCAUFL ADDRESS: 2995 Greenwood Dr. BY DELIVERY TO CLERK ON October 9, 19 � San Pablo, CA 94806 BY MIAIL 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.• October 10, 1996 tall BepyIyLOR, Cler �e � v�Gts— 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). ( ) 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: � BY: Deputy County Counsel I11. 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 (x) 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: io` ��'9� PHIL BATCHELOR, Clerk, ByC� �+���i�- '—� _. Deputy Clerk WARNING (Gov. code section 1,13) Subject to certain exceptions, you have only six (6) months from the 01le this notice was personally served or deposited in the mail to file a court actfon on this claim. See Goverpnient Code Section 945.6. You may seek the advice of an attorney of your choice in connection ;jith 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 %A.ILING 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 Notico to Claimant, addressed to the claimant as shown above. Dated: �� 2 5— �9`�'� BY: PHIL BATCHELOR bZZ,;,Le o-ae-,r"— _Deputy Clerk CC: Covnty Cc.;rse,; County Administrator C2aic to: BOAPID OF SUPERVISORS OF CONTRA COSTA COUM INSTRUCTIONS TO CLAIMANT A. Clai.s 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 105, County Administration Building, 651 Pine Street, Martinez, CA 9$553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the nate 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 Sea. 72 at the end of this for=. R£: Claim BBV Reserved for Clerks filing stamp RECEIVED Against trie County of Contra Costa ) Wria—9 = or ) ��.. �JJ d,_ : Rk yI1 gill t�JO District) CLERK BOARD OF SUPERVISORS Fill n name) ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of 2.nd in support of this claim represents as follows: 1. When did the damage or injury occur? "(Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury ? (Give full details; use extra paper if required) 84 6�iT� ��/�2 ropp 4C3- �/ �11C oov( �S / r ©au /C7 G�c �U� �`C,c�,P� h(o e.� l !/?a/cog �' 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? oho a 6a w� -rti� c r44c�e e-r �c��e u��,�i� ��'' �S ;;16 ,fie .� ��e ,��m o v,� 1 � �� rva rn - �. wnat are "e na—mes of.councv or district officers; servants or employees causing the or injury? what damage or injuries do you'.claim resulted? (Give full extent of injuries or damages claimed. Attach t estimates for auto damage. PitO�v q ow was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) �r ' /iaa�e e.� lfg, �U/J t�CC.C%� /v . r, Oce $. +Names and addresses of witnesses, doctors and hdspitals. `�� v --- ->---- - --• _ . _ _ dao "el5 Gar as ea r- ha.0A"- aft .11dkz ' 9. List the expenditures you made on account of this accident or injury: DATE ITEV. AMOUNT `e Gov. Code Sec. 910:2 provides: "The claim must be-signed by the claimant SM NOTICES TO: (Atto_rne ),1A ±o^ or by some person oa his behalf." Name and Address of Attorney -- (90 Address) LID Telephone No. Telephone No. - q �Q N O T I C E Section 72, of the Penal Code provides: "Every Pierson who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent Claim, bill,, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding -Tone thousan(i ($l,()00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand d,,..)11ars:..($10,000,. or b_y, both suchi^ risme u and fine- 'Y CLAIM BOARD Of SUPERVISOGS OF CONTRA COSTA COUNTY, CALIFORNIA October 22, 1996 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code AmoJnt; $11,000.00 Section 913 and 925.4. Please note �I ���� CLAIMANT: Ra jroop Singh Gill 0 C T 0 4 1996 ATTORNEY: Michael E. Brown, Esq. COUNTY COUNSEL SBN 063917 Date received MARTINEZ CALIF. ADDRESS: 515 Tennessee St. BY DELIVERY TO CLERK ON October 3, 1996 Vallejo, CA 94590 BY WAIL POSTMARKED: October 2, 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 4, 1996 pNIL ATCHELOR, Cler 0-047--- 81: Deputy /Ic 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: �rU to BY: Deputy County Counsel I1I. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present A) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: �0— 22 ' 9(p PHIL BATCHELOR, Clerk, By Z4: -f� �/s~�`O , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only si-c (6) months from the date this notice was personally served or deposited in the mail to file a court action on ttA s claim. Set 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. * -or-,Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty-of perjury that a am nolo, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez. California. postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: _ BY: PHIL BATCHELOR __Deputy Clerk CC: County Cc.,rSe' County Administrator Claim to: BOAPM 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 uhich 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 93553. 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 Rajroop Singh Gill ) RECEIVE® Against the County of Contra Costa ) ) OCT - 1996 or . District) CLERK BOARD Of SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 11,. 000 and in support of UW�''Ss claim w7s"ents as follaws: S VA person 1n Jury 1. When did the damage or injury occur? '(Give exact date and hour) Apr 24, 1996 at 07 : 55 2. Where did the damage or injury occur? (Include city and county) SR 24 W/B near I-580 O/C, Oakland Alameda County 3. How did the damage or injury occur? (Give full details; use extra paper if required) Please refer to CHP Oakland Traffic Collision Report #4-295 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? C.V.0 21703 , following too closely, C.V.C. 22350, speed too fast for conditions -5. wnat; are the nzmes of counLv or district officers, servants or employees causing or injury'? Robert Bruce Tavenier, CDL# C1680131 CA 2430 Shawnee Ct. , Fairfield CA 94533 ( 707) 428-399.1 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Damages Estimates ( 2). : $3, 500± and $2, 500± Injury Expenses :$3, 300±; Earnings Losses : $200/wk x 2 wk/.lost=$400 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Property Damage = $3, 000 Wages/Medical = $4, 000 TOTAL CLAIM $ .11 , 000. 00 Pain/Suffering = $4, 000 S. Names and addresses of witnesses, doctors and hospitals. Eric Knudson, D.C. 521 Capitol St. , Vallejo CA 94590 All witnesses declared in CHP Oakland Traffic Collision Rpt #4-295 9. List the expenditures you made on account of this accident or injury: DATE ITD-1 AMOUNT V. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by so n ifn his f." Name and Address of Attorney MICHAEL E. BROWN, Esq. t S SBN 063917 Rajro ping GiSlllgnature 515 Tennessee Street Vallejo CA 94590 1080 Stanford Ave #27 (Address) Emeryville CA 94608 Telephone No. 707-552-4111 Telephone No. 510-658-2982 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 s,:ch i-riso7j-le a--. d fine. MICHAEL E. BROWN ATTORNEY AT LAW 515 Tennessee Street Vallejo, California 94590 TELEPHONE(707)552-4111 FAX(707)552-0756 October 2, 1996 CLERK OF THE BOARD OF SUPERVISORS County Administration Building 651 Pine Street Room 106 Martinez CA 94553 RE: Claim for Personal Injury - Motor Vehicle Accident My Client : Rajroop Gill Loss Date : April 24, 1996 Dear Madam Clerk, Enclosed you will find the Original claim for personal injury with documents attached. Additionally, I have enclosed two (2) conformed copies of the completed claim form. Please stamp a conformed copy identifying the date you have received this claim, for my file, returning it in the stamped self-addressed envelope provided. Thank you for your assistance in this matter. Very truly yours, Michael E. Brown MEB:mm enclosure oDepartment of the Treasury—Internal Revenue Service, ' ss lFstrseon R 1040 U.S.Individual Income Tax Return X994 staple space. y—Do not write or sta L For the year Jan 1 -Dec 31,1994,or other tax year beginning 1994,ending 19 oMe No. Label Your first name M Last name Your social security No. RAJROOP S GILL 617-60-1609 Use the If a pint return,spouse's first name M Last name spouse's social Security No. IRS label. Otherwise, Home address(number and street),It you have a P.O.box,see instructions Apartment no. For Privacy Act please print ortype. 1080 STA1v�ORD AVE 27 and Paperwork Reduction Act Notice, 1City,town or post office.M you have a foreign address,see instructions. Sate VP Code see instructions. 0AKL,kND CA 94608 Yesl No Note,chedtirg PresidentialYos•win not change Election Do you want$3 to go to this fund?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X our tax or red" Campaign ► If a joint return,does yourspouse want$3 to go to this fund?. . . . . . . . . . . . . . . . . . . . . . . . . . . . rraland 1 X Single Filing Status 2 Married filing joint return(even if only one had income) 3 Married filing separate Rn.Enter spouse's SSN above&full name here . . . . . . . . . . . 4 Head of household(with qualifying person). If the qualifying person is a child but not your dependent, Check only enter this child's name here. . . . . . . . . . . . . . - one box. 5 2 Quaritying widow(er) with dependent child ear spouse died ► 19 6 a LXJ Yourself. If your parent(or someone else)can claim you as a dependent on his or No•of her tax return,do not check box 6a.But be sure to check the box on In 33b on 2, checkod on Exemptions P9 fiaand 6b . . . 1 b Spouse — . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Dependents: (2)ck if (3) If age t or older, (4) Dependenrs Mmos No.of your under dependent's social relationship in your children on (1)Name Ifirst,initial,and last name) age f security number to you home 6e who: •lived with If more than you . . . . . . 6 dependents, •didn't live see lnstrs with you due to divorce or separation. . . . Dependents on So not entered above . . . . . d If your child didn't live with you but is claimed as your dependent under a pre-1985 agreement rk here. . . . . . . . . . . . . . Add ntanbers ordered on e Total number of exemptions claimed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lines above 1 7 Wages,salaries,tips,etc.Attach Form(s)W-2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Income Be Taxable interest income.Attach Schedule B if over$400. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8a 64. Attach �•••v b Tax-exempt interest.Don't include on line 8a . . . . . . . . . . . . . . . Bbl «>>z Copy B of 9 Dividend income.Attach Schedule B if over$400. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 your Forms 10 Taxable refunds,credits,or offsets of state and local income taxes . . . . . . . . . . . . . . . . . . . . . . . 10 W-2,W-211,& 1099-R here. 11 Alimony received . . . .... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 If you did 12 Business income or(loss).Attach Schedule C or C-EZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 —70,802.1 not get a 13 Capital gain or(loss).If required,Attach Schedule D 13 W-2,see P 9 ( ) instructions. 14 Other gains or(losses).Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Enclose 15a Total IRA distributions ...... 159 Ib Taxable amount . . . . . . . . . . . . . 15b but do not 16a Tot pensions&annuities. .. . . 16a b Taxable amount . . . . . . . . . . . . . 16b attach any 17 Rental real estate,royalties,partnerships,S corporations,trusts,etc.Attach Sch E. . . . . . . . . . . . . 17 payment with your 18 Farm income or(loss).Attach Schedule F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 return. 19 Unemployment compensation .. . . .. . . . . . . . . . . . . 19 20a Social security benefits. . . I 20a J Ib Taxable amount . . . . . . . . . , . . 20b 21 Other income.- . 21 22 Add the amounts in the far right column for lines 7-21.This is our total Income. . . . . . . . . . . . 22 10, 866. Ad*ustments 23a Your IRA deduction .. .. .. . .. . . . . . . . . . . . . . . . . . . . . . . 23a to Income b spouse's IRA deduction 23b 24 Moving expenses.Attach Form 3903 or 3903-F . . . . . . . . . . . . . . 24 Caution:See 25 One-half of self-employment tax . . . . . . . . . . . . . . . . . . . . . . . 25 763. instructions. . . . . a' 26 Self-employed health insurance deduction. . . . . . . . . . . . . . . . . . 26 27 Keogh retirement plan and self-employed SEP deduction 27 .......... 28 Penalty on early withdrawal of savings . .. . . . .. . . . . . . . . . . . . 28 29 Alimony paid.Recipient's SSN . . . 29 cck 30 Add lines 23a through 29.These are your total adjustments . . . . . . . . . . . . . . . . . . . . . 1 30 763. Adjusted 31 Subtract ine 30 from line 22.This Is your ad)usted gross income.Ir loss than$25.296 and a child lived •r Gross Income with you (less than$9,000 d a cndd didrrr live with ul.sae Earned income Gradir in insirw ions. . . . . . . . . . . . . . . . . . 31 10, 103. Dtf31 " _' FDIA0112 11n5M Form 1040(1994) Form 1040 1994 P.AJROOP S GILL 617-60-1609 Page 2 32 Amount from line 31 (adjusted gross income) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 10, 103. Tax Me Ck if: You were 65/older, ❑ Blind: [] Spouse was 65/oicier, Blind .......... Computation Add the number of boxes checked above and enter the total here. . . . . . . . . . . . . . .. 33a b If your parent(or someone else)can claim you as a dependent,ck here. . . . . . . . . . 33 b c If you are married filing separately and your spouse itemizes deductions or you are a dual-status alien,see instructions and check here. . . . . . . . . . . . . . . . 33e ==== 34 En r Itemized deductions from Schedule A,line 29,or larger_ Standard ded shown below for your filing status.But if you ckd of any box on line Me or b,see instructions to find your standard your: ded.It you checked box 33c,your standard deduction is zero. •Single—$3,800 •Head of household—$5,600 •Married filing jointly 34 3,800. or Qualifying widower)—$6,350 a Married filing separately—$3,175 35 Subtract line 34 from line 32 . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35:.:. 6,303. 36 If In 32 is$83,850 or less,multiply$2,450 by the total no.of exemptions claimed on In 6e.If In 32 is over$83,850,see the instructions for the amount to enter. . . . . . . . . . . . . . ... . 36 2,450. If you want 37 Taxable income.Subtract In 36 from In 35.If In 36 is more than In 35,enter-0 . . . . . . . . . . . .. . . 37 1 3,853. the IRS to 38 Tax.Check if from a X Tax Table, bE]Tax Rate Schedules, c F] capitalGain Tax figure your tax,see Worksheet, or, dEForm 8615.Amount from Form(s)8814. . . . . "e 38 581.. instructions. 39 Additional taxes.Ck if from . . . . . . aE] Form 4970 b[:] Form 4972. . . . . . . . . . . . . . . . . 39 40 Add lines 38 and 39. . . .. . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . 40 581. 41 Credit for child and dep care exp.Attach Form 2441 . . . . . . . . . . 41 Credits 42 Credit for the elderly or the disabled.Attach Sch R . . . . . 42 43 Foreign tax credit.Attach Form 1116 . . . . . . . . . . . . . . . . . ... . . 43 44 Other credits.Check if from a Form 3800 b� Form 8396 cE] Form 8801 de Forth(spec) 45 Add lines 41.through 44 . . . . . . . . . . . . . . . . . . . 45 46 Subtract line 45 from line 40.If line 45 is more than line 40,enter-0. . . . . . . . . . . . . . . . . . . . . 46 47 Self-employment tax.Attach Schedule SE. . . . . . . . . . . . 47 1,S26. Other 48 Alternative minimum tax.Attach Form 6251 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Taxes 49 Recapture taxes.Ck if from aF� Form 4255 b[] Form 8611 c[:] Form 8828 49 50 SS and Medicare tax on tip income not reported to employer.Attach form 4137 . . . . . . . . . . . . . . . . . . . . 50 51 Tax on qualified retirement plans,including IRAs.If required,att Frm 5329 . . . . . . . . . . . . . . . . . . 51 52 Advance earned income credit payments from Form W-2 52 53 Add Ins 46-52.This is your total fax. . 53 2,107. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Payments 54 Federal income tax withheld.If any is from Form(s)1099,ck. . . . . . . 54 55 1994 estimated tax payments and amount applied from 1993 return . . . . . .. . . . . . . .. . . . . .. . . . . . . . . . . . . 55 56 Earned income credit.If required,att Sch EIC Attach Forms Nontaxable earned income:amount W-2,W-2G, and 1099-R and type 56V' #>?< 57 Amount paid with Form 4868(extension request) on page 1. . . . . . . . . . . . . 58 Excess social security and RRTA tax withheld . . . . . . . . . . . . . . 59 Other payments.Check if from. . . . C Form 2439 b❑ Form 4136 59 3 , > 60 Add Ins 54-59.These are your total payments . . . . . . 0. 60 Refund or 61 If line 60 is more than line 53,subtract line 53 from line 60.This is the amount you Overpaid . . . . . . . . . . . . . . 61 Amount You 62 Amount of line 61 you want Refunded to You . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 62 Owe 63 Amt of In 61 you want Applied to Your 1995 Est Tax. . . . . . . . . 011 63 .......... 64 If In 53 is more than In 60,subtract In 60 from In 53.This is the Amount You Owe. For details on how to pay,including what to write on your pmnt,see instructions. . . . . . . . . . . . . . . 64 2,216. 65 Estimated tax penalty.Also include on line 64 . . . . . . . . . . . . . . .1 65 1 109. �:'�::>�:>:�:�:�:�:>:::�:�::::� <:>`:::;::�;;;;.:•::.;;; Under penalties of perjury,I declare that 1 have examined this retirm and aecomparrying schedules and statements,and to the best of my knowledge and Sign hoist,they are true,correct,and complete.Declaration of preparer(other than taxpayer)is based on all infomration of which prepare,has any knowledge. Here Your signature Daft Youroccupation Keep a copy SELF-EMPLOYED of this return Spouse's signature.If a joint return,BOTH must sign. Date Spouse's occupation for your records. Paid • Data Check" Preps es Social Security No. Pre arees gn�atures ' ♦/l " se"�" � X 550-02-4440 Use Only Frrrrsname LAZARUS TAX SERVICE seaemployed) 890 53RD ST EIN "�.�. end address F0140t/2 tv,4ro4 OAKLAND CA ZIP 94608 y� k, -Schedule C Profit or Loss From Business OMB No.1545-0074 (Form 1040) (Sole Proprietorship) 1994 Department of the Treasury ' Partnerships,joint ventures,etc,must file Form 1065. Depart Revenue Tress 99 ' Attach to Form 1040 or Form 1041. ► See instructions for Schedule C(Form 1040). 09 Name of proprietor Social Security Number ISSN) RAJROOP S GILL 617-60-1609 A Principal business or profession,including product or service ► B Enter principal business code TAXICAB OPERATION 6114 C Business name.M no separate business name,leave black. D Employer ID no.(EIN),If any SUNNY CAB COMPANY E Business addr(include suite or room no.) ► 1080 STANFORD AVE, OAKLAND, CA 94608 ity,town or post office.state,8 ZIP code -------------------------------------------- ______ F Accounting method: (1) X Cash (2) Accrual (3) Other(specify) ► G Method(s)used to Lower of cost Other(attachDoes not apply(if value closing inventory: (11C cost (2)[] or market (3)E] explanation) (4) , checked,skip line H) Yes No H Was there any change in determining quantities,costs,or valuations between opening and closing inventory? If'Yes,'attach explanation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Did you'materially participate'in the operation of this business during 1994?If'No,'see instructions for limitations on losses. X J If you started or acquired this business during 1994,check here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................... I Income 1 Gross receipts or sales. Caution: ff this income was reported to you on Form W-2 and the Statutory employee'box on that form was checked,see the instructions and check here. . . . . . . . . . . . 1 24,250. 2 Returns and allowances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3 Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 24,250. 4 Cost of goods sold(from line 40 on page 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5 Gross profit.Subtract line 4 from line 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 24,250. 6 Other income,including federal and state gasoline or fuel tax credit or refund . . . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Gross income.Add lines 5 and 6 7 24,250. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . EX enseS. Enter expenses for business use of your home only on line 30. 8 Advertising . . . . . . . . . . . . . . . 8 84. 19 Pension and profit-sharing plans. . . . . . . . 19 9 Bad debts from sales 20 Rent or lease: or services . . . . . . . . . . . . . . . 9 a Vehicles,machinery,and equipment. . . . . . . . . . 20a 10 Car and truck expenses. . . . . . . 10 8,151. b Other business property . . . . . . . . . . . . . 20b 11 Commissions and fees . . . . . . . 11 21 Repairs and maintenance . . . . . . . . . . . . 21 1,166. 12 Depletion . . . . . . . . . . . . . . . . 12 22 Supplies(not included in Part III). . . . . . . . 22 1,451. 23 Taxes and licenses. . . . . . . . . . . . . . . . . 23 445. 13 Depreciation and section 24 Travel,meals,and entertainment: t:179 expense deduction on ,,,,....,,�...........................,,,.. (not included in Part III) . . . . . . . 13 a Travel . . . . . . . . . . . . . . . . . . . . . . . . .1 24a 14 Employee benefit programs b Meals and (other than on line 19) . . . . . . . . 14 entertainment . . . . ... . . 15 Insurance(other than health). . . . . . . 15 c Enter 50%of line 24b 16 Interest: > w subject to limitations. . . . . . a Mortgage(paid to banks,etc) . . . . . . 16a d Subtract line 24c from line 24b . . . . . . . . . 24d b Other. . . . . . . . . . . . . . . . . . 16b 25 Utilities. . . . . . . . . . . . . . . . . . . . . . . . 25 1,655. 17 Legal and professional services . . . . . 17 40. 26 Wages(less employment credits) . . . . . . . 26 18 Office expense. . . . . . . . . . . . .1 18 1 456. 27 Other expenses(from line 46 on page 2) . . . . . . . 27 28 Total expenses before expenses for business use of home.Add lines 8 through 27 in columns. . . . .. . . . . . . . 0. 28 13,448. 29 Tentative profit(loss).Subtract line 28 from line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 10,802. 30 Expenses for business use of your home.Attach Form 8829 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 31_ Net profit or(loss).Subtract line 30 from line 29. • If a profit,enter on Form 1040,line 12,and also on Schedule SE,line 2(statutory employees, see instructions).Fiduciaries,enter on Form 1041,line 3 . . . . . . . . . . . . . . . . . . . . • If a loss,you must go on to line 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ 31 10,802. 32 If you have a loss,check the box that describes your investment in this activity. • If you checked 32a,enter the loss on Form 1040,line 12,and also on Schedule SE,line 2(statutoryAll investment is employees,see instructions).Fiduciaries,enter on Form 1041,line 3. . . . . . . . . . . . . . . . . . . . . . . . . . . 32a0 at risk. Some investment • If you checked 32b,you must attach Form 6198. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . — 32bn is not at risk D181. For Paperwork Reduction Act Notice,see Form 1040 instructions. Schedule C(Form 1040)1994 FD¢0112 10/2194 Schedule C(Form 1040)1994 RAJR00P S GILL 617-60-1609 Page � -Cost of Goods Sold 33 Inventory at beginning of year.It different from last year's closing inventory, attach explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 34 Purchases less cost of items withdrawn for personal use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 35 Cost of labor.Do not include salary paid to yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 36 Materials and supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 37 Other costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 38 Add lines 33 through 37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 39 Inventory at end of year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 40 Cost of goods sold.Subtract line 39 from line 38.Enter the result here and on page 1,line 4 . . . . . . . . . . . . . . . 40 Information on Your Vehicle. Complete this part only if you are claimingcar or truck expenses on line 10 and are not required to file Form 4562 for this business.See the instructions for line 13 out if you must file. 41 When did you place your vehicle in service for business purposes?(month,day,year) a►------ 01/01/93.. 42 Of the total number of miles you drove your vehicle during 1994,enter the number of miles you used your vehicle for: a Business 2 8,107 b Commuting ------------- c Other ----------------- 43 Do you(or your spouse)have another vehicle available for personal use? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes [] No 44 Was your vehicle available for use during off-duty hours? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes MX No L"_j 45a Do you have evidence to support your deduction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NX X Yes No b If'Yes,'is the evidence written? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes H No Other Expenses. List below business expenses not included on lines 8-26 or line 30. ----------------------------------------------------------- ----------------------------------------------------------- --------------------------------------------------------- ----------------------------------------------------------- ----------------------------------------------------------- ----------------------------------------------------------- ------------------------------=---------------------------- ----------------------------------------------------------- ------------------------------------------- -------------------------------:---------------------------- --------------------------------------------------------- ----------------------------------------------------------- 46 Total other expenses.Enter here and on page 1,line 27 . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . FD[20112 10/21/94 Schedule SE Self-Employment Tax OMB No.1545-0074 (Form 1040) 1 994 - 0, See instructions for Schedule SE(Form 1040). Department of the Treasury Attach to Form 1040. 17 Internal Revenue Service (99) Name of person with son-employment income las shown on Form 1040) Social security number of person RAJROOP S GILL with self-employment income ► 617-60-1609 Who Must File Schedule SE You must file Schedule SE if: • You had net earnings from self-employment from other than church employee income(line 4 of Short Schedule SE or line 4c of Long Schedule SE)of$400 or more,or • You had church employee income of$108.28 or more.Income from services you performed as a minister or a member of a religious order is not church employee income. Note:Even if you have a loss or a small amount of income from self-employment,it may be to your benefit to file Schedule SE and use either optional method'in Part 11 of Long Schedule SE. Exception:It your only self-employment income was from earnings as a minister,member of a religious order,or Christian Science practitioner,and you filed Form 4361 and received IRS approval not to be taxed on those earnings,do not file Schedule SE.Instead, write'Exempt-Form 4361'on Form 1040,line 47. May I use Short Schedule SE or MUST I use Long Schedule SE? Did you receive wages or bps in 1994? Noy es I F L l Are you a minister,member of a religious order,or Yes Yes Christian Science practitioner who received IRS approval Was the total of your wages and tips subject to social not to be taxed on earnings from these sources,but you security or railroad retirement tax plus your net earnings owe self-employment tax on other earnings? from self-employment more than$60,600? 1No 1No Are you using one of the optional methods to figure your Yea Did you receive tips subject to social security or Medicare Yes net earnings. tax that you did not report to your employer? 1No as Did you receive church employee income reported on Y Form W-2 of$108.28 or more? 1No You may use Short Schedule SE below You must use Long Schedule SE Section A —Short Schedule SE. Caution:Read above to see if you can use Short Schedule SE. 1 Net farm profit or(loss)from Schedule F,line 36,and farm partnerships,Schedule K-1 (Form 1065), line15a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 Net profit or(loss)from Schedule C,line 31;Schedule C-EZ,line 3;and Schedule K-1 (Form 1065), line 15a(other than farming). Ministers and members of religious orders see instructions for amounts to report on this line.See instructions for other income to report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 10,802. 3 Combine lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 10,802. 4 Net earnings from self-employment.Multiply line 3 by 92.35%(.9235).If less than$400,do not file this schedule;you do not owe self-employment tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0, 4 9,976. 5 Self-employment tax.If the amount on line 4 is: •$60,600 or less,multiply line 4 by 15.3%(.153).Enter the result here and on Form 1040,line 47. 5 1,526. 'nX•More than 60 600 multiply t line 4b 2.9%(.029 .Then add$7,514.40 to the result.Enter the total here and on Form10 0line47. ` 6 Deduction forone-half of self-employment ment tox.Multi PIY line 5 by 50% (5). '. ' =?- ..?...• % r - ..-.Enter the result here and on Form 1040 line 25. . 6 763. D181 For Paperwork Reduction Act Notice,see Form 1040 instructions. Schedule SE(Form 1040)1994 - FOIA1101 10119/84 cs California Resident Income Tax Return 1994 540 `FEDERAL RETURN ATTACHMENT REQUIRED: YES NO DO NOT 617-60-1609 GILL 94 Do Not Write ATTACH RAJROOP S GILL in These Spaces LABEL P Step 1 AC Name and 1080 STANFORD AVE APT 27 A Address OAKLAND CA 94608 R RP FOR COMPUTERIZED USE ONLY 01 1 30 0 49 0 64 0 06 0 31 0 50 0 APE 0 09 0 35 0 51 0 3800 0 10 0 36 0 52 0 3803 0 12 0 37 42 53 0 SCHP 0 14 0 38 0 54 0 SCHG1 0 16 0 39 0 55 0 5870A 0 17 10103 41 0 56 0 5805 5805F 0 18 2431 43 0 57 0 20 107 44 0 58 0 21 65 45 0 59 0 23 0 46 42 60 0 28 0 47 0 61 42 29 0 48 0 63 0 Step 2 1x Single Filing 2 Married filing joint return(even if only one spouse had income) Check only one. 3 Married filing separate return.Enter spouse's SSN above and full name here . . . . . . . . Head of household(with qualifying person).If the qualifying person is a child 4 but not your dependent,enter child's name here. . . . . . . . . . . . . . . . . . . . . . . . 5H Qualifying widow(er)with dependent child.Enter year spouse died 19 Step 3 6 If someone can claim you(or your spouse,if married)as a dependent on their return,check the box here.If you checked the boxes on Exec line 6 and line 1,skip line 7 through line 10,enter-0-on line 11.If you checked the box on line 6 and any other box,see instructions. . • 6 7 Personal:If you checked box 1,3,or 4 above,enter 1.If you checked box 2 or 5,enter 2 . . . . . . . . . . . . : . . . . 7 Do not enter 8 Blind:If you or your spouse is visually impaired,enter 1.If both are visually impaired,enter 2 . . . . . . . . . . . . . . 8 dollar amounts in the yes. 9 Senior:If you or your spouse is 65 or older,enter 1.If both are 65 or older,enter 2. . . . . . . . . . . . . . . . . . . . • 8 10 Dependents:Enter name and relationship. Do not include yourself,your spouse or the person listed on line 4. Pyr dip Side 1 to Side 2 here. Enter the total no.of dependents 10 11 Total number of exemptions.Add fine 7 through tine 10.. . . . . . . . . . . . . . . 0 . . . . . . . . . . . . . . . . . . . . . . . i1 Step 4 12 State wages from your Form(s)W-2,box 17. . . . . . . . . . . . . . . . . . • 12 Taxable 13 Federal adjusted gross income from your Form 1040,line 31,your Form 1040A, Income line 16 or your Form 1040EZ,line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 10,103. Sine your check or 14 California adjustments—subtractions.Enter the amount from Schedule CA(540),line 31,column B . . . . . . . • 14 money order here 15 Subtract line 14 from line 13.If less than zero,enter the result in parentheses . . . . . . . . . . . . 15 10,103. 16 California adjustments—additions.Enter the amount from Schedule CA(540),line 31,column C . . . . . . . . . • 16 17 California adjusted gross income.Combine line 15 and line 16. . . . . . . . . . . . . . . . . . . . . • 17 10,103. 18 Enter your standard deduction OR your Itemized deductions. . . . . . . . . . . . . . . . . . . . • 18 2,431. 19 Subtract line 18 from line 17.This is your taxable income. If less than zero,enter-0 . . . . . .. . 19 7,672. Step 5 20 Tax Check if from: x Tax Table H Tax Rate Schedule LJ FfB 3800 or I LJ FTB 3803 . • 20 107. Tax 21 Exemption credits.Ck one: Qx in 21 instructions E] In 21 worksheet or ❑ Schedule P(540) . @)21 65. 22 Subtract line 21 from line 20.If less than zero,enter-0.. . . . . . . . . . . . . 22 42. 23 Tax.Check if from [] Schedule G-1 and from [] form FTB 5870A. . . . . . . . . . . . . . • 23 24 Add line 22 and line 23. Continue to side 2. . .�. . 24 42. For Privacy Act Notice,see instructions. WA3912 12/2394 ( Form 540 C1 1994 Side 1 ! cs RAJROOD S GILL 617-60-1609 Step 6 25 Amount from Side 1,line 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . !. . . . . . . . . . . . . 25 42. Credits ?� 28 Enter credit name code no. amount ► 28 29 Enter credit name code no. amount ► 29 30 Enter credit name code no. amount ► 30 31 To claim more than three credits,see instructions. . . . . . . . . . . . • 31 33 Add line 28 through line 31.These are your total credits . . . . . . . . . . . . . . . . . . . . . . . . . 33 34 Subtract line 33 from line 25. If less than zero,enter-0 . . . . . . . . . . . . . .,. . . . . . . . . . . . . 34 42. Step 7 35 Alternative minimum tax.Attach Schedule P(540) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 35 Other Taxes 36 Other taxes and credit recapture from forms FTB 3518,FTB 3501,FTB 3805P, FTB 38052 or FTB 3806 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 36 37 Add line 34 through line 36.This is your total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 37 42. Step 8 38 California income tax withheld.Enter total from your 1994 Payments Form(s)W-2,W-2G, 1099-MISC and 1099-R . . . . . . . . . . . . . . . . ■ 38 39 1994 CA estimated tax and amt applied from your 1993 return.Include the amount from form FTB 3519 or Schedule K-1(541) . . . . . . . . . . . . . . . . . . . . . . ■ 39i 41 Excess California SDI(or VPDI)withheld. . . . . . . . . . . . . . . . . . . ■ 41I 42 Add line 38 through line 41.These are your total payments.. . . . . . . . . . .!. . . . . . . . . . . . 42 Step 9 43 If line 42 is larger than line 37,subtract line 37 from line 42.This is your overpaid tax . . . . . . 43 0. Overpaid 44 Amount of line 43 you want applied to your 1995 estimated tax. . . . . . . . .I. . . . . . . . . . . . ■ 44 Tax or 45 Subtract line 44 from line 43.This is the amount of overpaid tax available this year. . . . . . . . ■ 45 Tax Due 46 If line 42 is less than line 37,subtract line 42 from line 37.This is the tax due . . . . . . . . . . . 46 42. Step 10 47 Contribution to California Seniors Special Fund. . . . . . . . . . . . . . . • 47 Contributions You may make a contribution of$1 or more to: Staple acopy 48 Alzheimer's Disease/Related Disorders Fund . . . . . . . . . . . . . . . . • 48 v''Form(s)r,d 49 California Fund for Senior Citizens. . . . . . . . . . . . . . . . . . . . . . . • 49I toss-a here. 50 Rare and Endangered Species Preservation Program . . . . . . . . . . • 50' 51 State Children's Trust Fund for the Prevention of Child Abuse . . . . . • 51 i 52 California Breast Cancer Research Fund. . . . . . . . . . . . . . . . . . . • 521 53 Veterans Memorial Account . . . . . . . . . . . . . . . . . . . . . . . . . . . • 53'' 54 California Firefighters'Memorial Fund. . . . . . . . . . . . . . . . . . . . . • 54 55 California Public School library Protection Fund. . . . . . . . . . . . . . • 55, 56 California Olym is Training Fund. . . . . . . . . . . . . . . . . . . . . . . . • W California Election 57 Your political party. . . . amt($25 max) . . ► 57 Campaign Fund _ 58 Spouse's political party . amt($25 max) . . ► 58 59 Total contributions.Add line 47 through line 58.. . • 59 0. Step 11 60 Subtract line 59 from line 45.You have a REFUND OR NO AMOUNT DUE.Mail your return to: Rotund or Franchise Tax Board,Image Processing,P.O.Box 942840,Sacramento,CA 94240-0009. . . . . . . . . . . . ■ 60 Amount 61 Add line 46 and line 59.This is the AMOUNT YOU OWE.Make a check or money order You Owe payable to'Franchise Tax Board'for the full amount you owe.Write your social security number and'1994 Form 540'on it Attach it to your return and mail to: Franchise Tax Board,P.O.Box 942867,Sacramento,CA 94267-0001 . . . . . . . . . . . . . . ■ 61 42. Step 12 62 Interest and late return and late payment penalties. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Interest and 63 Underpayment of estimated tax.If form FTB 5805 or 5805F is attached,check here . . . .F� ■ 63 Penalties 64 If you do not need California income tax forms mailed to you next year,check here . . . . . . . • 64 Sign IMPORTANT: See the instructions for information on who must attach a copy of their federal 4 Here income tax return and federal schedules. It is unlawful to Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements, forge a spouse's and to the gest of my knowledge and belief,it is true,correct and complete. signature. Your signature Spouse's signature(it filing jointly,both must sign) Date X X Signature of paid preparer(declaration of preparer is based on all information of which preparer has any knowladge.) Prepmer's SSN/FEIN 550-02-4440 Firm's name for yours if self-employed) Firm's address 890 53RD STREET LAZARUS TAX SERVICE OAKLAND CA 94608 Side 2 Form 540 C 1 1994 CAIA3912 1223/94 r aDepartment of the Treasury-Internal Revenue Service ii 1040 U.S.Individual Income Tax Return 1995 ss IRS useony—Donotwriteorstapleinthisspace. For the year Jan 1-Dec 31,1995,or other tax year beginning 1995,ending ,19 °5as.4 Label Your First Name ho Last Name Your Social Security No. RAJROOP S GILL 617-60-1609 Use the H a Joint Return,Spouse's First Name hit Last Name Spouse's Social Security No. IRS label. Otherwise, Home Address(number and stroll).If You Haws P.O.Box,see instructions. ApartmentNo. For Privacy Act please print and Paperwork or type. 1080 STANFORD AVE 27 Reduction Act Notice, City,Town or Poet Office.if You Have a Foreign Address,See Instructions. state ZIP Code see instructions. OAKLAND CA 94608 Yes No Note:Chcift Presidential Do you want$3 to go to this fund?. . . . .. . .. . . . . . .. . . . . . . . .. . .. . . .. . . . . .. . .. . . X Youor 11 111r nor c0iong- Election um larCampaign a- If a joint return,does ours . . . . . . .. . . . . . . . . .. . .. . . . . . use want$3 to o to this fund? . yourroAmd. 1 X Single Filing Status 2 Married filing joint return(even if only one had income) 3 Married filing separate rtn.Ester spouse's SSN above&full name here . . . . . . . .. . 01' 4 Head of household(with qualifying person). If the qualifying person is a child but not your dependent, enter this child's name here. . 0' Check only . . . . . .. . ... one box. 5 Q Qualifying widow(er) with dependent child ear spouse died► 19 6 a LXJ Yourself.If your parent(or someone else)can claim you as a dependent on his or a b her tax return,do not check box 6a.But be sure to check the box on In 33b on 2. Exemptions ea and tib . . . 1 bM Spouse I c Dependents: (2) Depend—social (3)Dependents (4)Mos No.of your sewdty number.If born relationship in your home children on 1 First name Lastnana inigg%seeirswctions to you in 1005 6e who: • lived with If more than YOU• • • • 6 dependents, •didn't Ihre see Instmseparation with you due to divorce a . . . Dependents on do not entered -above. . . . d H your cMId didn't live with you but is claimed as your dependent under a pre-1985 agreement,check hen. .. . .. . .. . . . Add ntnnbers enter"on 9 Total number of exemptions claimed . ones ► 1 7 Wages,salaries,tips,etc.Attach Form(s)W-2 . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . 7 Income Be Taxable interest income.Attach Schedule B if over$400 . . . . . . . . . . . . . .. . . . . .. . . as 63. Attach b Tax-exempt Interest.Don't include on fine Sa . .. . ... .. . . . . . I 8 b .:M Copy B of 9 Dividend income.Attach Schedule B if over$400 . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 9 your Forms 10 Taxable refunds,credits,or offsets of state and local income taxes 10 W-2,W-2G,3 1099•R here. 11 Alimony received . .. . ..... . . .. . . . . .. . .. . . . . .. . . . . . .. . . . . . . . .. . .. . . . . . 11 If you did• 12 Business income or(loss).Attach Schedule C or C-EZ. . . . . . . .. . . . . . . . . . . . .. .... . . . 12 10,698.1 not get a 13 Capital gain or(loss).If required,Attach Schedule D . .. . .. . .. . . . . . .. . .. . . . . . . . .. . . 13 W-2,see' instructions. 14 Other gains or(losses).Attach Form 4797. .. . .. . .. . . . . . .. . .. . .. . . . . . .. . .. . . 14 15a Total IRA distributions . .. . .. 156 b Taxable amount . .. . . . . .. . . 15b Enclose but do not 16a Tot pensions&annuities. .. . . 1681 b Taxable amount . .. . .. . .. . . 16b attach your 17 Rental real estate,royalties,partnerships,S corporations,trusts,etc.Attach Sch E . . . . .. . . . . . . 17 payment and payment 18 Farm income or(loss).Attach Schedule F. . . . .. . .. . . .. . . . . .. . . . . . . . .. . . .. . . . . . 18 voucher. 19 Unemployment compensation . . .. . .. . . . . . .. . .. . . . . . . 19 20a Social security benefits... 206 b Taxable amount . .. . . . . . . . 20b 21 Other income. . ____ _________________________ _____ 2t 22 Add the amounts in the far right column for lines 7-21.This is our total Income. . . . . 22 10,761. 23a Your IRA deduction. .. . ... .. . . .. . .. . .. . .. . .. . . . . . . 23a Adjustments w _4 to Income b spouse's IRA deduction. .. . .. . ... . .. . .. . .. . .. . . . . . . 23b •' :.' 24 Moving expenses.Attach Form 3903 or 3903-F . .. . .. . .. . . . . 24 25 One-half of self-employment tax. .. . ...... . . .. . .. . .. . . . . 25 756. T?^� 26 Self-employed health insurance deduction. .. . .. . .. . .. . 26 27 Keogh and self-employed SEP plans.If SEP,check. .. . . . .PEI 27 28 Penalty on early withdrawal of savings . .. .. . . . . . . . . . .. . .. 28 cz, 29 Alimony paid.Recipient's SSN 29 :r; • 30 Add lines 23a through 29.These are your total adjustments. . 30 756. Adjusted 31 Subtract inti 30 from inti 22 This is your adpated goal bteome.If)"s,den$26,673 and dull Armed `.. Gross Income with Qess then$9,230 d a drild didnt Arv.widen you),see'Earned income Credit in instruotiona 31 10,005. BAA�� FDLA0112 1ti2M Form 1040(1995) �3y Schedule C Profit or Loss From Business OMB No.1545-0074 (Form 1040) (Sole Proprietorship) 1995 Department oftftoTreasury ► Partnerships,joint ventures,etc,must file Form 1065. internal Flavone Service 99 ► Attach to Form 1040 or Form 1041. ► See Instructions for Schedule C(Form 1040). 09 Name of Proprietor Social Security Number(SSN) RAJROOP S GILL 617-60-1609 A Principal Business or Profession,Including Product or service B Enter Principal Business Code► TAXICAB OPERATION 6114 C Business Name.B No Separate Business Name,Leave Blanc D Employs ID No.(EIN),If Any SUNNY CAB COMPANY E & rlrssAddVinlu tesujiWm .) ► 1080 STANFORD AVE,_APT 27,_OAKLAND,_CA 94608'_______________ F Accounting method: (I)IXI Cash (2) Accrual (3)LJ Other(specify) ► _________ G Wthod(s)used to Lower of cost Other(attach Does not apply(if value closing inventory: (10 Cost (2)[] or market (3)[] explanation) (4)�X checked,skip line H) Yes No H Was there any change in determining quantities,costs,or valuations between opening and dosing inventory? If'Yes,'attach explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Did you'materially participate'in the operation of this business during 1995?If'No,'see instructions for limit on losses. . . . . . . . . . . X J If Lou started or acquired this business during 1995,check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Income 1 Gross receipts or sates.Caution:If this income was reported to you on Form W-2 and the Statutory employee'box on that form was checked,see the instructions and check here. . . . . . . . . . . 1 23,673. 2 Returns and allowances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3 Subtract line 2 from line 1. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 23,673. 4 Cost of goods sold(from line 40 on page 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5 Gross profit.Subtract line 4 from line 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 23, 673. 6 Other income,including federal and state gasoline or fuel tax credit or refund. . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Gross Income.Add lines 5 and 6 Is. 7 23,673. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . Expenses. Enter a nses for business use of your home only on line 30. 8 Advertising. . . . . . . . . . . . . . 8 19 Pension and profit-sharing plans . . . . . . . 19 9 Bad debts from sales 20 Rent or lease: -01. or services . . . . . . . . . . . . . . 9 a Vehicles,machinery,and equipment . . . . . . . . . 20a 10 Car and truck expenses. . . . . . 10 9,133. b Other business property. . . . . . . . . . . . . 20b 11 Commissions and fees . . . . . . 11 21 Repairs and maintenance . . . . . . . . . . . 21 12 Depletion. . . . . . . . . . . . . . . 12 22 Supplies(not included in Part 111) . . . . . . . 22 844. 23 Taxes and licenses. . . . . . . . . . . . . . . . 23 13 Depreciation and section entertainment:t and meals,l vrae,m , enerta 179 expense deduction 24 T - V (not included in Part Ili) . . . . . . 13 a Travel. . . . . . . . . . . . . . . . . . . . . . . . 24a 14 Employee benefit programs b Meals and (other than on line 19). . . . . . . 14 entertainment . . . . . . . 15 Insurance(other than health). . . . . . 15 c Enter 50%of line 24b 16 Interest: 77— "` subject to limitations. . . . . a Mortgage(paid to banks,etc). . . . . . 16a d Subtract line 24c from line 24b . . . . . . . . 24d b Other . . . . . . . . . . . . . . . . . 16b 25 Utilities . . . . . . . . . . . . . . . . . . . . . . . 25 2,850. 17 Legal and professional services. . .. . . 17 60. 26 Wages(less employment credits). . . . . . . 26 18 Office expense . . . . . . . . . . . 118 1 88. 27 Other expenses(from line 46 on page 2). . . . . . . 27 28 Total expenses re expenses for business use of home.Add lines 8 through 27 in columns . . . . . . . . . . . . 28 12,975. 29 Tentative profit(loss).Subtract line 28 from line 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 10, 698. 30 Expenses for businuse of your home.Attach Form 8829 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 i 31 Net profft or(loss). btract line 30 from line 29. • If a profit,enter on Form 1040,line 12,and also on Schedule SE,line 2(statutory employees, see instructions).Estates and trusts,enter on Form 1041,line 3 . . . . . . . . . . . . . . . . . . • If a loss,you must go on to line 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ 31 10, 698. 32 If you have a loss,check the box that describes your investment in this activity. • Ify ou checked 32a,enter the loss on Form 1040,line 12,and also on Schedule SE,line 2(statutory All investment is employees,see instructions).Estates and trusts,enter on Form 1041,line 3. . . . . . . . . . . . . . . . . . . . . . 32 all at risk Some investment • If you checked 32b,you must attach Form 6198 32b is not at risk. BAA For Paperwork Reduction Act Notice,see Form 1040 Instructions. Schedule C(Form 1040)1995 t# Y' FDQ0112 11102/95 Schedule C(Form 1040)1995 RAJROOP.S GILL 617-60-1609 Paget Cost of Goods Sold 33 Inventory at beginning of year.If different from last year's dosing inventory, attach explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 34 Purchases less cost of items withdrawn for personal use . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 34 35 Cost of labor.Do not include salary paid to yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 38 Materials and supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 37 Other costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 38 Add lines 33 through 37. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 39 Inventory at end of year. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 40 Cost of goods sold.Subtract line 39 from line 38.Enter the result here and on page 1,line 4 . . . . . . . . . . . . . . 40 Information on Your Vehicle.Complete this part only if you are claiming car or truck expenses on line 10 and are not required to file Form 4562 for this business.See the instructions for line 13 to find out if you must file. 41 When did you place your vehicle in service for business purposes?(month,day,year) ►_____ 01/01/93. 42 Of the total number of miles you drove your vehicle during 1995,enter the number of miles you used your vehicle for: a Business ____________30_444bCommuting ________________ cOther . ----------------- 43 Do you(or your spouse)have another vehicle available for personal use? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .QX Yes No 44 Was your vehicle available for use during off-duty hours?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes QX No 45a Do you have evidence to support your deduction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X YesNo b If Ties,'is the evidence written?. .A Yes A No FORME Other Expenses.Ust below business expenses not included on lines 8-26 or line 30. ,rt ----------------------------------------------------------- ------------------------------------------------------------ ------------------------------------------------------------- ----------------------------------------------------- ------------------------------------------------------------ ----------------------------------------------------------- ----------------------------------------------------------- ------------------------------------------------------ 48:'Total other expenses.Enter here and on a 1,line 27 . 46 FD¢0112 08/14195 Cs California Resident Income Tax Return 1995 ; 540 APE FEDERAL RETURN ATTACHMENT REQUIRED: QX YES n NO DO NOT 617-60-1609 GILL 95 Do Not Write ATTACH RAJROOP S GILL In Theses aces LABEL P Step 1 AC Name and 1080 STANFORD AVE 27 A Address OAKLAND CA 94608 R RP FOR COMPUTERMED USE ONLY 01 1 30 0 49 0 64 0 06 0 31 0 50 0 65 0 09 0 35 0 51 0 APE 0 10 0 36 0 52 0 3800 0 12 0 .37 36 53 0 3803 0 14 0 38 0 54 0 SCHP 0 16 0 39 0 55 0 SCHG1 0 17 10005 41 0 56 0 5870A 0 18 2487 43 0 57 0 5805 5805F 0 20 102 44 0 58 0 21 66 45 0 59 0 23 0 46 36 60 0 28 0 47 0 61 0 29 0 48 0 62 36 Step 2 11 Single Fging Status 2 Married filing joint return(even If only one spouse had income) Chedt only am 3 Married filing separate return.Enter spouse's SSN above and full name here. . . . . . . . Head of household(with qualifying person).If the qualifying person is a 4H child but not your dependent,enter child's name here . . . . . . . . . . . . . . . . . . 5 Qualifying widow(er)with dependent child.Enter year spouse died 19 Step 3 6 If someone can claim you(or your spouse,if married)as a dependent on their return,check the box here.If you checked the boxes on Exemptions line 6 and line 1,skip line 7 through line 10,enter-0-on line 11.If you checked the box an line 6 and any other box,see instructions . • 6 7 Personal:If you checked box 1,3,or 4 above,enter 1.If you checked box 2 or 5,enter 2 . . . . . . . . . . . . . . . . 7 1 00 sot a+tw 8 Blind:If you(or if married,your spouse)are visually impaired,enter 1.If both are visually impaired,enter 2. . . . . 8 dors amount in the tom• 9 Senior:If you(or if married,your spouse) are 65 or older,enter 1.If both are 65 or older,enter 2. . . . . . . . . . • 9 10 Dependents:Enter name and relationship.Do not include yourself,your spouse or the person listed on line 4. Attach check ;:;Z"ordw Enter the total no.of dependents 10 0 11 Total number of exemptions.Add line 7 through line 10 11 1 Step 4 12 State wages from your Form(s)W-2,box 17. . . . . . . . . . . . . . . . . • 12 0.1 Taxable 13 Federal AGI from your Form 1040,line 31;your Form 1040A line 14 or your Form 1040EZ,line 4. . . . . . . . . . 13 10,005. Income 14 California adjustments—subtractions.Enter the amount from Schedule CA(540),line 31,column B. . . . . . . • 14 Attach ewy d v= 15 Subtract line 14 from line 13.If less than zero,enter the result in parentheses . . . . . . . . . . . 15 10,005. tomaal w-2.w-20 16 California adjustments—additions.Enter the amount from Schedule CA(540),line 31,column C. . . . . . . . . • 16 and 1099-R hwe. 17 California adjusted gross income.Combine line 15 and line 16. . . . . . . . . . . . . . . . . . . . • 17 10,005. 18 Enter your CA standard deduction OR your CA Itemized deductions . . . . . . . . . . . . . . • 18 2,487. 19 Subtract line 18 from line 17.This is 4our taxable income.If less than zero,enter-0 . . . . . . . 19 7,518. Step 5 20 Tax Check if from: X Tax Table LJ Tax Rate Schedule LJ FTB 3800 or LJ FTB 3803. • 20 102. Tax 21 Exemption credits.Check one: QX Flowchart [] Worksheet I Worksheet II,III or Schedule P(540) . . . . . Q 21 66. 22 Subtract line 21 from line 20.If less than zero,enter-0 . . . . . . . . . . . . . . . . . . . . . . 22 36. 23 Tax.Check if from ❑ Schedule Crt and from form FTB 5870A. . . . . . . . . . • 23 24 Add line 22 and line 23. Continue to side 2 . 24 36. For PMvacy Act Notice,see Instructions. CA"12 12/15196 Form 540 C1 1995 Side 1 •'s Form 1040 1995 RAJROOP S GILL 617-60-1609 Page 2 32 Amount from line 31(adjusted gross income). . . . . . . . . . 32 10,005. T33a Check it You were 65/older, ❑ Blind; Spouse was 65/older, Blind <f Vii: . Computation Add the number of boxes checked above and enter the total here . .. . .. . .. . . .. 33a w; a b If your parent(or someone else)can claim you as a dependent,ck here . .. . .. . . . 33 b .a:•�? c If you are married filing separatelyand your ~ spouse itemizes deductions •�: or you are a ctual-status alien,see instructions and check here. .. . .. . . . . . .. . . 33e � v •. 34 Enter Itemized deductions from Schedule A,line 28,or :., ' the ! w2ri Standard dad shown below for your filing status.But If you ckd $^k larger : Of any box on firm 33a or b,see instructions to find your standard your dad.If you checked box 33c,your standard deduction is zero. ` ' •Single—$3,900 •Head of household—$5,750 •Married filing jointly 34 3,900. or Qualifying widow(er)—$6,550 •Married filing separately—$3,275 = = 35 Subtract line 34 from line 32 . .. ... . .. . . .. . . . . .. . .. ... . .. . . .. . . . . .. . . . . . . . 35 6,105. 36 If In 32 is$86,025 or less,multiply$2,500 by the total no.of exemptions Claimed on In 6e,If In 32 is over$86,025,see the instructions for the amount to enter. . . . .. . .. . . . . . . . 36 2,5 0 0. If you want 37 Taxable Income.Subtract In 36 from In 35.If In 36 is more than In 35,enter-0. . . . . .. . . . . . .. . 37 3,605. the IRS to 38 Tax.Check N from e X Tax Table, b❑Tax Rate Schedules, cE] Capital Gain Tax figure your tax,see a Worksheet, or, d Form 8615.Amount from Form(s)8814. .. . . Ole 38 544* Instructions. 39 Additional taxes.Check N from. .. . . a[] Form 4970 bQ Form 4972. .. . .. . .. . . .. . 39 40 Add lines 38 and 39.. ► 40 544. . . .. ... . . .. . .. . . . . . . . .. . . . . . .. . .. . .. . . . . . . . . . . . . 41 Credit for child and dep care exp.Attach Form 2441 . . . . .. . .. . 41 Credits 42 Credit for the elderly or the disabled.Attach Sch R. . . . . .. . . . . . 42 <. 43 Foreign tax credit.Attach Form 1116 . . .. . . . . . .. . . . 43 44 Other credits.Check if from a Form 3800 b[:]Form 8396 c[] Form 8801 de Form(spec) 44 4 45 Add lines 41 through 44 . .. . .. .... . . .. . . . . . . . .. .... .. . . .. . .. . .. . .. . .. . .. . 45 46 Subtract line 45 from line 40.If line 45 Is more than line 40,enter-0 . .. . . . . . . . . .. . . . . . . go. 544. .. . . . . . . . . .. . . . . . . 47 Self-employment tax.Attach Schedule SE. .. . .. . .. . . .. . .. . . . . .. . . . . .. . . . . . .. . . 47 1,512. Other 48 Alternative minimum tax.Attach Form 6251... . .. . .. . . . .. . .. . 48 Taxes 49 Recapture taxes.Ck if from a[:] Form 4255 b� Form 8611 cForm 8828. . 49 50 SS and Medicare tax on tip income not reported to employer.Attach Form 4137 . .. . .. . ... . . . . .. . .. . . . 50 51 Tax on qualified retirement plans.Including IRAs.If required,att Form 5329. .. . .. . .. . . . . . .. . 51 52 Advance earned income credit payments from Form W-2 . .. . .. . . . . . .. . . . . .. . . . . .. . . 52 53 Household employment taxes.Attach Schedule H. . . . .. . .. . . .. . .. . .. . .. . . . . .. . . . . 53 54 Add Ins 46-53 This is your total tax 54 2, 056. .Payments 55 Federal income tax withheld.N any is from Form(3)1099,aleck. .. .. 55 56 1995 estimated tax payments and amount applied ` from 1994 return. ..... ... .. .. . .. . .. . .. . .. . .. .. .. . 56 :• 57 Earned locants credit Attach Schedule EIC N you have a qualifying , Attach Forms child.Nontaxable earned income:amount. .. .. W-Z W 2G, and 1099-R and type. .. le, 57 on page 1. 58 Amount paid with Forth 4868(extension request) ... . . . . . . . . . 58 59 Excess social security and RRTA tax withheld . .. . . . . .. . . .. . 59 60 Other payments.Check if from. .. a[I Form 2439 b[] Form 4136 . ... ... .. ..... .. . .. . . . . .. . .. .. . 60 61 Add lines 55-60.These are our total ents. . 61 Refund or 62 If line 61 is more than line 54,subtract line 54 from line 61.This is the amount you Overpaid . .. . .. . . . . . .. 62 Amount You 63 Amount of line 62 you want Refunded to You . .. . .. . .. . ... . 63 Owe. 64 Amt of In 62 you want Applied to Your 1996 Est Tax . . . . .. . . 64MINE ;.• 65 If In 54 Is more than In 61,subtract In 61 from In 54.This is the Amount You Owe. = For details on how to pay Includng using Form 1040-V,Payment Voucher,see instr. . . . .. . .. . . 652,166. 66 Estimated tax penalty.Also include on line 65. . 66 112. t :< ? .v >< wz:>< ca!` Under penaaiee of penury,I declare that 1 have examined thisMum and accompanying schedules and statemerris,and to the beet of my knowledge and Sign t oW.dM are tnre,oorreck and cornpift.De ianni n of preparer(athera,an taxpayer)re based on all irdormetion d which preperer has any knowledge. Here YourSignawre Date YourOca+psam Keep acopy ► TAXI DRIVER of this return Spa i signewre.n a Join Flaturn,BOTH Must Sign. Data spouse's Occupation for.your records. ► Paid ` ' Dads Check itPreparers social SecuriV Preoiies. So"= ► 4��!ZARUS 02/23/961190K'"'p�� X 550-02-4440 fa Use Only rimNama TAX SERVICE 890 53RD STREET oN e"d A4d1e" OAKLAND CA zip cede 94608 A. :; ;: FDutwlx rtrzaras Cs RAJROOP S. GILL 617-60-1609 Step 6 25 Amount from Side 1,line 24. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 36. Credits 26 Enter credit name code na amount ► 28 29 Enter credit name code no, amount ► 29 30 Enter credit name code no. amount ► 30 31 To daim more than three credits,see instructions . . . . . . . . . . . • 31 33 Add line 28 through line 31.These are your total credits . . .. . . . . . . . . . . . . . . . . . . . . . 33 34 Subtract line 33 from line 25.If less than zero,enter-a 34 36. Step 7 35 Alternative minimum tax.Attach Schedule P(540). . . . . . . . . . . . . . . . . . . . . . . . . . . . • 35 Other Taxes 36 Other taxes and credit recapture from forms FTB 3518,FTB 3501,FTB 3M5P,. FTB 38051 or FTB 38M . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . • 36 37 Add line 34 through line 36.This is your total tax. . • 37 36. Step 8 38 California income tax withheld.Enter total from your 1995 Form(s)W-2,W-2G, Payments 1099-MISC and 1099•R Also,attach forms to Side 1 . . . . . . . . . . . . . . . . ■ 38 39 1995 CA estimated tax and amount applied from your 1994 return.Include the amount from form FTB 3519 or Schedule K-1(541). . . . . . . . . . . . .. . . . ■ 39 41 Excess California SDI(or VPDI)withheld. . . . . . . . . . . . . . . . . . ■ 41 42 Add line 38 through line 41.These are your total payments . 42 Step 9 43 If line 42 Is larger than line 37,subtract line 37 from line 42.This Is your overpaid tax. . . . . . . 43 0.1 Overpaid 44 Amount of fine 43 you want applied to your 1996 estimated tax. . . . . . . . . . . . . . . . . . . . ■ 44 Tax or 45 Subtract One 44 from line 43.This Is the amount of overpaid tax available this year . . . . . . . ■ 45 Tax Due 46 If line 42 Is less than line 37,subtract line 42 from line 37.This is the tax due. . . . . . . . . . . . 46 36. Step 10 47 Contribution to California Seniors Special Fund. . . . . . . . . . . . . . • 47 Contributions You may make a contribution of$1 or more to: 48 Alzheimer's Disease/Related Disorders Fund. . . . . . . .. . . . . . . • 48 49 California Fund for Senior Citizens. . . . . . . . . . . . .. . . . . . . . . • 49 50 Rare and Endangered Species Preservation Program . . .. . . . . . • 50 51 State Children's Trust Fund for the Prevention of Child Abuse . . . . • 51 52 California Breast Canoer Research Fund. . . . . . . .. . . . .. . . . . • 52 53 Veterans Memorial Account:. . . . . . . . . . . . . . . . . . . . . . . . . • 53 54 California Firefighters'Memorial Fund. . . . . . . .. . . . .. . . . . . . • 54 55 California Public Sdtool Ubrary Protection Fund . . . . . . . . . . . . . • 55 S6 DARE California(Drug ANse Resistance Education)Fund . . . . . . . . . . . . • 56 S7 California Military Museum Fund. . . . . . . . . . . . . . . . . .. . . . . • 57 California Election SS Your political party . .. amt(125 max) 110-S8 t Campaign Fund 59 Spouse's political party.. amt(1125 max) 10,59 60 Totn'contributions.Add line 47 through line 59. • 60 0. Step 11 61 Subtract fine 60 from line 45.You have a REFUND or NO AMOUNT DUE Mail your return to: Refund or Image Processing,Franchise Tax Board,P.O.Box 942840,Sacramento,CA 94240-0009 . . . . . . . . . . . ■ 61 Amount 62 Add fine 46 and line 60.This is the AMOUNT YOU OWE Make a check or money order You Ows payable to'Franchise Tax Board'for the full amount.Write your social security number and'1995 Form 540'on it.Attach it to your Form 540 and mail to: Franchise Tax Board,P.O.Box 942867,Sacramento,CA 94267-0001 . . . . . . . . . . . . . ■ 62 36. Step 12 63 Interest and late return and late payment penalties . . . . . . . .. . ... . . . . . . . . . . . . . . . . 63 Interest and 64 Underpayment of estimated tax.If form FTB 5805 or 5805F is attached,check here . . . ■ 64 Penalties 65 If you do not need California income tax forms mailed to you next year,check here. . . . . . . • 65 Sign.'- IMPORTANT:See the Instructions for Information on who must attach a copy of their federal 4 g-. Income tax return and federal schedules. Here ,� schedules and statements, a is unlawful to Under penaKies of 1 declare that I haus examined uric return,induct' aocarpanying forge a spouse's and to the best of my knowbdge and belief,it's true,correct and oonpleEe agneturo Your signature Spouse's signature(d filing aril joint,bath must sign) Dots X X Signature of paid preparer(declarnfon of preparer fa based on a0 idormadon of which preparsr has anyfowwfedge) Preparees SSN/FEIN 550-02-4440 Frmfs name(or yours it 9Wenpbyed) Firm's address 890 5 3RD STREET --------------------------------- LAZARUS TAX SERVICE OAKLAND CA 94608 x„ Side-.2 Form 540 C1 1995 CA"12 12flSW . fifi STATE OF CALIFORNIA TRAFFIC COLLISION REPORT PACE / OF/(� SPECIAL CONDITIONS NO INI H&R FEL CITY JUDICIAL DISTRICT NUMBER 2 [] OAKLAND OAKLAND NO KILL H&R MISD COUNTY DIST BEAT 4-295 0 ALAMEDA 25 C*Stars: 07SN6401 COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC p OFFICER I.D. 0 S/R 24 W/B 04124196 0755 9370 1010103 C A MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: 100 feet E of MP 24 .ALA 1 . 84 WEDNESDAY p]YES [] NO 0 N [j AT INTERSECTION WITH: STATE HWY REL Pq OR: 100 feet E of 1-580 O/C M YES f I NO NONE PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH YR MAKE/MODEL/COLOR LICENSE NUMBER STATE 1 B3418483 ICA C G 92 NISSAN PATHFNDR RED 4N22570 CA DRIVER NAM E(FIRST,MIDDLE,LAST) P] GILBERT JOHN GODINEZ PEDES- STREET ADDRESS OWNER'S NAME SAME AS DRIVER TRrV 2921 WILDFLOWER DR. PAR`KJEDC1TY/STATEIZIP OWNER'S ADDRESS SAME AS DRIVER IE rTLl ANTI OCH CA 94509 BICY- SEX HAIR I EYES I HEIGHT I WEIGHT BIRTHDATE RACE DISPO OF VEHICLE ON ORDERS OF: [] OFFICER K] DRIVER []OTHER C'n M BRN BRN 6-00 185 04114159 DRIVEN AWAY BY DRIVER OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT p] REFER TO NARRATIVE[] [] (510) 706-9073 (5 1 0) 208-8866 CHP USE ONLYEDESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA VEHICLE TYPE INSURANCE CARRIER POLICY NUMBER I []NONE K]MINOR ALLSTATE 067735320 07/29 O1 .[ ]MAJOR []TOTAL DIR TRV I ON STREET OR HIGHWAY T65 PCF W S R 24 PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH YR MAKE/MODEL/COLOR LICENSE NUMBER STATE 2 81850082 CA C G 91 ACURA INTEGRA WHITE 2WDC409 CA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DRIVER NAMEMRST,MIDDLE,LAST) P] JOHN CARL BOGARD PEDES- STREET ADDRESS OWNER'S NAME �] SAME AS DRIVER TRrV 6251 CYPRESS AVE . PALRKJED CITY/STATE/ZIP OWNER'S ADDRESS �] SAME AS DRIVER VErTL EL CERRITO CA 94530 BICY- SEX HAIR I EYES I HEIGHT I WEIGHT BIRTHDATE RACE DISPO OF VEHICLE ON ORDERS OF: [] OFFICER P] DRIVER []OTHER CL[I M BRN HZL 5-0812401 . 03 28 35' BERRY BROS. TOWING (510) 465-7215 OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT K] REFER TO NARRATIVE[] [] (510) 235-9288 (510) 769-6001 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE []UNK []NONE []MINOR NONE IN VEHICLE 01 I [4MoD.[]MAJOR []TOTAL DIR TRV I ON STREET OR HIGHWAYSPD LMT PCF ........... ........ W S R 24 65 PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH YR MAKE/MODEL/COLOR LICENSE NUMBER STATE 3 A0817400 CA C G 92 . FORD.CRNVIC SILVER. . 2XLS612 . .CA DRIVER NAM E(FIRST,MIDDLE,LAST) WILLIAM CLARENCE JOHNS - _ PEDES STREET ADDRESS OWNER'S NAME ] SAME AS DRIVER TRL`A�r 2714 HARVEST LANE PARK1ED CTTY/STATEMP OWNER'S ADDRESS �] SAME AS DRIVER vErTL ANTIOCH CA 94509 BIClY1- SEX I HAIR I EYES I HEIGHT WEIGHT BIRTHDATE RACE DISPO OF VEHICLE ON ORDERS OF: [] OFFICER n DRIVER []OTHER CLfj M BLK BRN 5-11 170 09112136 DRIVEN AWAY- BY DRIVER OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT p] REFER TO NARRATIVE[] [] (510) 757-6848 (5,10) 987-2366 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE [.]UNK []NONE �]MINOR AAA 79-77-05-1 01 I []MOD.[]MAJOR []TOTAL DIR TRV ON STREET OR HIGHWAY SPD LMT PCF W S R 24 165 22350 PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NA DATE REVIEWED CRANE K 010103 . M Yes F IN.r I N/A STATE OF CALIFORNIA TRAFFIC COLLISION REPORT PAGE 2 oP/G SPEQAL CONDITIONS NO IN) H&R FEL CITY JUDICIAL DISTRICT NUMBER 2 [] OAKLAND OAKLAND NO KILL H&R MISD COUNTY DIST BEAT 4-295 0 ALAMEDA 25 C*Stars: 07SN6401 COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC B OFFICER I.D. L S/R 24 W/B 04124196 0755 9370 010103 C A MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: 0 100 feet E of MP 24 ALA 1 . 84 WEDNESDAY MYES [] NO N [I AT INTERSECTION WITH: STATE HWY REL P9 OR: 100 feet E of 1-580 O/C M YES r I No 14 NONE PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH YR MAKE/MODEUCOLOR LICENSE NUMBER STATE 4 U0044191 ICA C J 91 GEO PRIZM4DR SILVER 2XFT888 CA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DRIVER NAM E(FIRST,MIDDLE,LASI) M PAULINE PO CHIN TANG PEDES- STREET ADDRESS OWNER'S NAME �] SAME AS DRIVER TIry 717 SWEETWATER DR. PARKED CRY/STATE/ZIP OWNER'S ADDRESS �] SAME AS DRIVER VEPTL DANVI LLE CA 94506 BICY. SEX HAIR I EYES I HEIGHT I WEIGHT BIRTHDATE RACE DISPO OF VEHICLE ON ORDERS OF: [] OFFICER �] DRIVER []OTHER CLfj F BLK BRN 5-0110951 06 07 54 BERRY BROS . TOWING (510) 465-7215 OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE [] [ (5 1 0) 736-5430 (5 1 0) 268-7715 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA VEHICLE TYPE - INSURANCE CARRIER POLICY NUMBER []UNK []NONE * []MINOR STATE FARM 836 17 61 E21 0 5 E 01 I [X]MOD.[]MAJOR []TOTAL DIR TRYFNSTR' EET OR HIGHWAY SPD LMT PCF W 24 165 7 PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH YR MAKE/MODEUCOLOR LICENSE NUMBER STATE 5 B3784749 CA C G 88 DODO DIPLOMAT GREEN4R29924 CA DRIVER NAME(FIRST•MIDDLE,LAST) M RAJROOP SINGH GILL PEDES- STREET ADDRESS OWNER'S NAME SAME AS DRIVER TRry 1080 STANFORD AVE. #27 PARKED CITY/STATE/LIP OWNER'S ADDRESS ] SAME AS DRIVER IErf EMERYVILLE CA 94608 BICY- SEX HAIR I EYES I HEIGHT I WEIGHTBIRTHDATE RACE DISPO OF VEHICLE ON ORDERS OF: [] OFFICER P] DRIVER []OTHER CLn M IBLK BRN 5-10 180 . 11 03 54' DRIVEN AWAY BY DRIVER OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT K] REFER TO NARRATIVE[] [] (510) 6 58-2 9 82 (5 1 0) 693-1500 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE []UNK []NONE �]MINOR NATIONAL CONTINENTAL CP 6 6 7 91515 01 []MOD.[]MAJOR []TOTAL •,;; DIR TRV I ON STREET OR HIGHWAY JSPD LMT PCF ... ....... W S R 24 65 PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH YR MAKE/MODEUCOLOR LICENSE NUMBER STATE 6 C1680131 CA C G 95 CHEVY CORSICA WHITE E021970 CA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DRIVER. NAME(FIRST,MIDDLE,LAST) �] ROBERT BRUCE TAVENIER PEDES. STREET ADDRESS OWNER'S NAME [] SAME AS DRIVER TR`A�J 2430 SHAWNEE CT. CONTRA COSTA COUNTY #1417 PA�RKED CIIY/STATE/LIP OWNER'S ADDRESS [] SAME AS DRIVER VErf FAIRFIELD CA 94533 2467 WATERBIRD WAY, MARTINEZ, CA 94553 ' BICY- SEX HAIR I EYES I HEIGHT WEIGHTBIRTHDATE RACE DISPO OF VEHICLE ON ORDERS OF: [] OFFICER K] DRIVER []OTHER CLrj M IBLN BLU 6-01 220 07 14 64 DRIVEN AWAY BY DRIVER OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT p] REFER TO NARRATIVE[] [] (7 0 7) 428-3991 (5 10) 313-2256 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE []UNK []NONE []MINOR SELF INSURED 01 I MOD.[]MAJOR []TOTAL "' DIR TRV I ON STREET OR HIGHWAY SPD LMT PCF W S R 24 65 PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED CRANE K 010103 Igy. No N/A STATE OF CALIFORNIA - TRAFFIC COLLISION REPORT PAGE -� OF 14 SPECIAL CONDITIONS NO IN] H&R FEL CITY JUDICIAL DISTRICT NUMBER 2 [] OAKLAND OAKLAND NO KILL H&R MISD COUNTY DIST BEAT 4-295 0 ALAMEDA 25 C*Stars: 07SN6401 COLLISION OCCURRED ON: MO DAY YEAR TIME(14W) NCIC/ OFFICER I.D. 0 S/R 24 W/B 04124196 0755 9370 010103 C A MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: 100 feet E of MP 24 ALA 1 . 84 WEDNESDAY P]YES [] NO 0 N (J AT INTERSECTION WITH: STATE HWY REL pQ OR: 100 feet E of 1-5 8 0 O/C M YES f 1 NO NONE PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH YR MAKE/MODEL/COLOR LICENSE NUMBER STATE 7 N2597613 ICA C G 90 FORD F250 P/U BLUE 3Z97291 CA . . . . . . . . . . . . . . DRIVER NAME(FIRST,MIDDLE,LASI) F,] MICHAEL FREDRICK BOEHMER PEDES- STREET ADDRESS OWNER'S NAME [] SAME AS DRIVER TR[AT 3256 ESTERO DR. SHWARTZ/LINDHEIM PARKED CITY/SPATE/ZIP OWNER'S ADDRESS [ SAME AS DRIVER vEg1�L SAN RAMON CA 94583 PO BOX 2145, OAKLAND, CA 94621 BICIY-J SEX HAIR I EYES I HEIGHT WEIGHT BIRTHDATE RACE DISPOOF VEHICLE ON ORDERS OF: [] OFFICER �] DRIVER []OTHER c'rl M RED BLU 5-11 170 11 110156 DRIVEN AWAY BY DRIVER OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT ] REFER TO NARRATIVE [] [] (510) 556-1730 (5 1 0) 562-1980 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE []UNK []NONE []MINOR NORTHBROOK NAT' L CAO 2 3 5 9 2 7 22 I pqMOD.[]MAJOR []TOTAL DIR TRV ON STREET OR HIGHWAY SPD LMT PCF W S R 24 65 PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFELY VEH YR MAKE/MODEL/COLOR LICENSE NUMBER STATE 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DRIVER NAM E(FIRST,MIDDLE,LASI) PEDES- STREET ADDRESS OWNER'S NAME [] SAME AS DRIVER TR ff PARKED CITY/STATE/LIP OWNER'S ADDRESS [] SAME AS DRIVER VE�II�L BCLnICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE DISPOOF VEHICLE ON ORDERS OF: [] OFFICER [] DRIVER []OTHER • OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT [] REFER TO NARRATIVE[] [] CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE []UNK []NONE []MINOR []MOD.[]MAJOR []TOTAL DIR TRV I ON STREET OR HIGHWAY SPD.LMT PCF I L PARTY DRIVER'S LICENSE NUMBER SAFETY VEH YR MAKE/MODEL/COLOR LICENSE NUMBER SLATE _ 9 . . . . . . . . . ..... . ... . . . . . . . .. . . . . . . . . . . . DRIVER NAME(FIRST.MIDDLE,LASp _ PEDES- STREET ADDRESS OWNER'S NAME [] SAME AS DRIVER - TR ff PARKED CITY/STATE/ZIP OWNER'S ADDRESS [] SAME AS DRIVER VEPTL BICYSEX HAIR I EYES HEIGHT WEIGHT BIRTHDATE RACE DISPO OF VEHICLE ON ORDERS OF: [] OFFICER [] DRIVER []OTHER nCLI i OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT[] REFER TO NARRATIVE[] [] CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE []UNK []NONE []MINOR []MOD.[]MAJOR []TOTAL DIR TRV ON STREET OR HIGHWAY SPD LMT PCF PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED CRANE K 010103 KlY. rIN. flNIA STATE OF CALIFORNIA TRAFFIC COLLISION CODING PACE OF/G DATE OF ORIGINAL INCIDENT TIME(2400) NCIC NUMBER OFFICER I.D. NUMBER 04 - 24 - 96 0755 9370 010103 4-295 OWNERS NAME/ADDRESS NOTIFIED PROPERTY DESCRIPTION OF DAMAGE DAMAGE SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VEH OCCUPANTS MIC BICYCLE-HELMET 1-DRIVER A-NONE IN VEHICLE L-AIR BAG DEPLOYED 0-NOT EJECTED 2 to 6-PASSENGERS B-UNKNOWN M-AIR BAG NOT DEPLOYED DRIVER 1-FULLY EJECTED 7-STA.WGN,REAR C-LAP BELT USED N-OTHER V-NO 2-PARTIALLY EJECTED 1 2 3 8-RR.OCC.TRK.OR VAN D-LAP BELT NOT USED P-NOT REQUIRED W-YES 3-UNKNOWN 9-POSITION UNKNOWN E-SHOULDER HARNESS USED 4 5 6 0-OTHER F-SHOULDER HARNESS NOT USED CHILD RESTRAINT PASSENGER G-LAP/SHOULDER HARNESS USED Q-IN VEHICLE USED. X-NO 7 H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 1-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK(')SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR I MOVEMENT PRECEDING LIST NUMBER(//)OF PARTY AT FAULT TRAFFIC CONTROL DEVICES1 2 3 TYPE OF VEHI1[ CLE 1 2 3 COLLISION A VC SECTION VIOLATED: CITED A CONTROLS FUNCTIONING I A PASSENGER CAR/STN.WGN. X A STOPPED 3 22350 NO B CONTROLS NOT FUNCTIONING' B PASSENGER CAR W/TRAILER B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING' C CONTROLS OBSCURED I C MOTORCYCLE/SCOOTER C RAN OFF ROAD C OTHER THAN DRIVER' X D NO CONTROLS PRESENT/FACTOR D PICKUP OR PANEL TRUCK D MAKING RIGHT TURN D UNKNOWN' TYPE OF COLLISION E PICKUP/PANEL TRK.W/TLR. E MAKING LEFT TURN E FELL ASLEEP- A HEAD-ON F TRUCK OR TRUCK TRACTOR F MAKING U TURN WEATHER(MARK 1 TO 2 ITEMS) B SIDESWIPE G TRK.IIRK.TRACTOR W(TLR. G BACKING A CLEAR X C REAR END H SCHOOL BUS X X H SLOWING/STOPPING X B CLOUDY D BROADSIDE I OTHER BUS 1 PASSING OTHER VEHICLE X C RAINING E HIT OBJECT 1 EMERGENCY VEHICLE 1 CHANGING LANES D SNOWING F OVERTURNED K HWY.CONST.EQUIPMENT I K PARKING MANEUVER E FOG/VISIBILITY: G VEHICLE/PEDESTRIAN L BICYCLE I L ENTERING TRAFFIC F OTHER': H OTHER': M OTHER VEHICLE I M OTHER UNSAFE TURNING G WIND MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN N XING INTO OPPOSING LANE LIGHTING A NON-COLLISION O MOPED 0 PARKED X A DAYLIGHT B PEDESTRIAN ASSOIAD P MERGING B DUSK-DAWN X C OTHER MOTOR VEHICLE 1 2 3 OT MRARK I TO2ITEMS�OR Q TRAVELING WRONG WAY C DARK-STREET LIGHTS D MOTOR VEH ON OTHER ROADWAY A VC SECTION VIOLATION:CITE R OTHER': D DARK-NO STREET LIGHTS E PARKED MOTOR VEHICLE E DARK-STREET LIGHTS NOT FUNCTION F TRAIN B VC SECTION VIOLATION:CITE ROADWAY SURFACE G BICYCLESOBRIETY-DRUG PHYSICAL A DRY H ANIMAL: C VC SECTION VIOLATION:CITE 1 2 3 (MARK 1 TO 2 ITEMS) X B WET - - - X X X A HAD NOT BEEN DRINKING C SNOWY-ICY I FIXED OBJECT: E VIS.OBSCURED: B HBD-UNDER INFLUENCE D SLIPPERY(MUDDY.OILY.ETC.) F INATTENTION• C HBD-NOT UNDER INFLUENCE ROADWAY CONDITIONS 1 OTHER OBJECT: G STOP&GO TRAFFIC D HBD-IMPAIRMENT UNK.' MARK 1 TO 2 ITEMS PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE' , A HOLES,DEEP RUTS- X A NO PEDESTRIAN INVOLVED X X X I PREVIOUS COLLISION I F IMPAIRMENT-PHYSICAL* B LOOSE MATERIAL ON RDWY• B CROSSING IN XWALK/INTERSECTION I J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY- C CROSSING IN XWALK NOT AT K DEFECTIVE VEH.EQUIP.:CITE H NOT APPLICABLE INTERSECTION D CONSTRUCTION-REPAIR ZONE I SLEEPY/FATIGUED E REDUCED ROADWAY WIDTH D CROSSING NOT IN CROSSWALK L UNINVOLVED VEHICLE SPECIAL INFORMATION F FLOODED* E IN ROAD-INCLUDES SHOULDER M OTHER*: A HAZARDOUS MATERIAL G OTHER*: F NOT INROAD N NONE APPARENT B SEATBELT FAILURE X H NO UNUSUAL CONDITIONS G APPROACHING/LEAVING SCHOOL BUS T 0 RUNAWAY VEHICLE SKETCH I MISCELLANEOUS d STATE OF CALIFORNIA TRAFFIC COLLISION CODING PAGE S OF 10:?4+ DATE OF ORIGINAL INCIDENT ME(2400) NCIC NUMBER OFFICER I.D. NUMBER TI 04 - 24 - 96 0755 9370 010103 14-295 • OWNERS NAME/ADDRESS TOTiFiBD PROPERTY DESCRIPTION OF DAMAGE DAMAGE SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VEH OCCUPANTS M/C BICYCLE-HELMET 1-DRIVER. A-NONE IN VEHICLE L-AIR BAG DEPLOYED 0-NOT EJECTED 2 to 6-PASSENGERS B-UNKNOWN M-AIR BAG NOT DEPLOYED DRIVER 1-FULLY EJECTED 7-STA.WGN.REAR C-LAP BELT USED N-OTHER V-NO 2-PARTIALLY EJECTED 1 2 3 1-RR.OCC.TRK.OR VAN D-LAP BELT NOT USED P-NOT REQUIRED W-YES 3-UNKNOWN 9-POSITION UNKNOWN E-SHOULDER HARNESS USED 4 5 6 0-OTHER F-SHOULDER HARNESS NOT USED CHILD RESTRAINT PASSENGER G-LAP/SHOULDER HARNESS USED Q-IN VEHICLE USED X-NO 7 H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK(')SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR MOVEMENT PRECEDING LIST NUMBER GI)OF PARTY AT FAULT TRAFFIC CONTROL DEVICES FF 6 TYPE OF VEHICLE 4 S 6 COLLISION A VC SECTION VIOLATED: CITED A CONTROLS FUNCTIONING A PASSENGER CAR/STN.WGN. X I A STOPPED 3 22350 NO B CONTROLS NOT FUNCTIONING- B PASSENGER CAR W/TRAILER B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING' C CONTROLS OBSCURED C MOTORCYCLE/SCOOTER C RAN OFF ROAD C OTHER THAN DRIVER' X D NO CONTROLS PRESENT/FACTOR D PICKUP OR PANEL TRUCK D MAKING RIGHT TURN D UNKNOWN' TYPE OF COLLISION E PICKUP/PANEL TRK.W/TLR. E MAKING LEFT TURN E FELL ASLEEP' A HEAD-ON F TRUCK OR TRUCK TRACTOR F MAKING U TURN WEATHER(MARK 1 TO ITEMS) R SIDESWIPE G TRK./I'RK.TRACTOR W/TLR. G BACKING A CLEAR X C REAR END H SCHOOL BUS X X H SLOWING/STOPPING X B CLOUDY D BROADSIDE 1 OTHER BUS I PASSING OTHER VEHICLE X C RAINING E HIT OBJECT J EMERGENCY VEHICLE J CHANGING LANES D SNOWING F OVERTURNED K HWY.CONST.EQUIPMENT K PARKING MANEUVER E FOG/VISIBILITY: G VEHICLE/PEDESTRIAN L BICYCLE L ENTERING TRAFFIC F OTHER': H OTHER-: M OTHER VEHICLE M OTHER UNSAFE TURNING G WIND MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN N XING INTO OPPOSING LANE LIGHTING A NON-COLLISION 1 O MOPED O PARKED X A DAYLIGHT B PEDESTRIAN P MERGING OTHER ASSOCIATED FACTOR B DUSK-DAWN X C OTHER MOTOR VEHICLE 4 151 6 1 MARK 1 TO 2ITEMS I Q TRAVELING WRONG WAY C DARK-STREET LIGHTS D MOTOR VEH ON OTHER ROADWAY A VC SECTION VIOLATION:CITE R OTHER': D DARK-NO STREET LIGHTS E PARKED MOTOR VEHICLE X 122350 NO E DARK-STREET LIGHTS NOT FUNCTION F TRAIN. B VC SECTION VIOLATION:CITE ROADWAY SURFACE C BICYCLESOBRIETY-DRUG ICAL A DRY H ANIMAL: C VC SECTION VIOLATION:CITE 4 5 6 (MARKII TO 2 ITEMS) X B WET X X X A HAD NOT BEEN DRINKING C SNOWY-ICY I FIXED OBJECT: E VIS.OBSCURED: B HBD-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,ETC.) F INATTENTION• C HBD-NOT UNDER INFLUENCE ROADWAY CONDITIONS OTHER OBJECT: G STOP&GO TRAFFIC D HBD-IMPAIRMENT UNK.' MARK 1 TO 2 ITEMS PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE' A HOLES-DEEP RUTS* X A NO PEDESTRIAN INVOLVED X X X I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' B LOOSE MATERIAL ON RDWY' B CROSSING IN XWALKJINTERSECTION J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' C CROSSING IN XWALK NOT AT K DEFECTIVE VEH.EQUIP.:CITE H NOT APPLICABLE . INTERSECTION D CONSTRUCTION-REPAIR ZONE I I SLEEPY/FATIGUED 2` E REDUCED ROADWAY WIDTH D CROSSING NOT IN CROSSWALK L UNINVOLVED VEHICLE SPECIAL INFORMATION F FLOODED' E IN ROAD-INCLUDES SHOULDER M OTHER': A HAZARDOUS MATERIAL G OTHER': F NOT IN ROAD N NONE APPARENT B SEATBELT FAILURE X H NO UNUSUAL CONDITIONS G APPROACHINGILEAVING SCHOOL BUS O RUNAWAY VEHICLE SKETCH MISCELLANEOUS- STATE OF CALIFORNIA TRAFFIC COLLISION CODING PAGE GOF/G DATE OF ORIGINAL INCIDENT TIME(2400) NCIC NUMBER 7FOTFI�CERLD. NUMBER 04 - 24 - 96 0755 9370 03 4-295 OWNERS NAME/ADDRESS NOTIFJED PROPERTY' DESCRIPTION OF DAMAGE DAMAGE SEATING POSITION OCCUPANTS MIC BICYCLE-HELMET SAFETY EQUIPMENT EJECTED FROM VEH 1-DRIVER A-NONE IN VEHICLE L-AIR BAG DEPLOYED 0-NOT EJECTED 2 to 6-PASSENGERS B-UNKNOWN M-AIR BAG NOT DEPLOYED DRIVER l-FULLY EJECTED 7-STA.WON.REAR C-LAP BELT USED N-OTHER V-140 2-PARTIALLY EJECTED 1 2 3 8-RR.OCC.TRK.OR VAN D-LAP BELT NOT USED P-NOT REQUIRED W-YES 3-UNKNOWN 9-POSITION UNKNOWN E-SHOULDER HARNESS USED 6 5 6 0-OTHER F-SHOULDER HARNESS NOT USED CHILD RESTRAINT PASSENGER G-LAP/SHOULDER HARNESS USED Q-IN VEHICLE USED X-NO 7 H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 1•PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK(')SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR I I MOVEMENT PRECEDING LIST NUMBER(J)OF PARTY AT FAULT TRAFFIC CONTROL DEVICES ,7 8 9 TYPE OF VEIUCLE 7 8 9 COLLISION A VC SECTION VIOLATED: CITED A CONTROLS FUNCTIONING A PASSENGER CAR/STN.WGN. A STOPPED 3 22350 NO B CONTROLS NOT FUNCTIONING' B PASSENGER CAR W/TRAILER B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING' C CONTROLS OBSCURED C MOTORCYCLE/SCOOTER C RAN OFF ROAD C OTHER THAN DRIVER' X D NO CONTROLS PRESENT/FACTOR D PICKUP OR PANEL TRUCK D MAKING RIGHT TURN D UNKNOWN, TYPE OF COLLISION. - E PICKUP/PANELTRK.W/TLR. E MAKING LEFT TURN E FELL ASLEEP' A HEAD-ON F TRUCK OR TRUCK TRACTOR F MAKING U TURN WEATHER(MARK 1 TO 2 ITEMS) B SIDESWIPE G TRK./TRK.TRACTOR W/J'LR., G BACKING A CLEAR X C REAR END H SCHOOL BUS X H SLOWING/STOPPING X B CLOUDY D BROADSIDE I I OTHER BUS I PASSING OTHER VEHICLE X C RAINING E HIT OBJECT J EMERGENCY VEHICLE : J CHANGING LANES D SNOWING F OVERTURNED K HWY.CONST.EQUIPMENT K PARKING MANEUVER E FOG/VISIBILITY: G VEHICLE/PEDESTRIAN L BICYCLE\ L ENTERING TRAFFIC F OTHER': H OTHER': M OTHER VEHICLE M OTHER UNSAFE TURNING G WIND MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN N XING INTO OPPOSING LANE LIGHTING A NON-COLLISION 0 MOPED 0 PARKED X A DAYLIGHT B PEDESTRIAN P MERGING HERB DUSK-DAWN X C OTHER MOTOR VEHICLE 7M89 � MARK I'TO 2 I EA SCTOR Q TRAVELING WRONG WAY C DARK-STREET LIGHTS D MOTOR VEH ON OTHER ROADWAY A VC SECTION VIOLATION:CITE R OTHER': D DARK-NO STREET LIGHTS E PARKED MOTOR VEHICLE X 22350 V. C.NO E DARK-STREET LIGHTS NOT FUNCTION F TRAIN B VC SECTION VIOLATION:CITE ROADWAY SURFACE G BICYCLE SOBRIETY-DRUG ICAL A DRY H ANIMAL: C VC SECTION VIOLATION:CITE 1718 9 (MARK II TO 2 ITEMS) X B WET X I A HAD NOT BEEN DRINKING C SNOWY-ICY 1 FIXED OBJECT: E VIS.OBSCURED: B HBD-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,ETC.) F INATTENTION' C HBD-NOT UNDER INFLUENCE ROADWAY CONDITIONS 7 OTHER OBJECT: G STOP&GO TRAFFIC D HBD-IMPAIRMENT UNK.' MARK I TO 2 ITEMS PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE• A HOLES,DEEP RUTS* X A NO PEDESTRIAN INVOLVED X 1 PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' B LOOSE MATERIAL ON RDWY' B CROSSING IN XWALK/INTERSECTION J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' C CROSSING IN XWALK NOT AT K DEFECTIVE VEH.EQUIP.:CITE H NOT APPLICABLE 1 INTERSECTION D CONSTRUCTION-REPAIR ZONE f SLEEPY/FATIGUED ; E REDUCED ROADWAY WIDTH D CROSSING NOT IN CROSSWALK L UNINVOLVED VEHICLE SPECIAL INFORMATION F FLOODED' E IN ROAD-INCLUDES SHOULDER M OTHER*: A HAZARDOUS MATERIAL G'OTHER*: F NOT IN ROAD N NONE APPARENT B SEATBELT FAILURE X H NO UNUSUAL CONDITIONS G APPROACHING/LEAVING SCHOOL BUS 0 RUNAWAY VEHICLE SKETCH MISCELLANEOUS STATE OF CALIFORNIA INJURED/WITNESSES/PASSENGERS PAGE 7 OF /G DATE OF COLLISION TIME(2400) NCIC NUMBER OFFICER I.D. NUMBER 04 - 24 - 96 0755 9370 010103 4-295 EXTENT OF INJURY ('X' ONE) INJURED WAS ('X' ONE) WITNESS PASSENGER AGE SEX PARTY SEAT SAFETY E]ECTED ONLY ONLY FATAL SEVERE OTHER VISIBLE COMPLAINT NUMBER POS. EQUIP. INJURY INJURY INJURY OF PAIN DRIVER PASS. PED. BIKE OTHER 61 M X X 2 1 G 0 NAME/D.O.B./ADDRESS TELEPHONE JOHN CARL BOGARD 03-28-35 H-6251 CYPRESS AVE. , EL CERRITO, CA, 94530 (510) 235-9288 (510) 769-6001 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: WILL SEE OWN DOCTOR DESCRIBE INJURIES: COMPLAINT OF CHEST PAIN VICTIM OF VIOLENT CRIME NOTIFIED 41 IF I I I I X I X I I I 1 1 4 1 1 1 J 1 0 NAME/D.O.B./ADDRESS TELEPHONE PAULINE PO CHIN TANG 06-07-54 H-717 SWEETWATER DR. , DANVILLE, CA, 94506 (510) 736-5430 (510) 268-7715 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: WILL SEE OWN DOCTOR DESCRIBE INJURIES: COMPLAINT PF PAIN TO NECK, LEFT HAND,WRIST AND ARM VICTIM OF VIOLENT CRIME NOTIFIED X 29 Im 5 1 5 1 D NAME/D.O.B./ADDRESS TELEPHONE DARRELL DONNELL BENEFIELD 03-13-67 H-1071 54TH ST. #B, EMERYVILLE, CA, 94608 �'� (510) 595-9613 (510) 653-4100 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED -T NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: -� VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME LD NUMBERMO. DAY YR. REVIEWER'S NAME MO. DAY YR. CRANE K 010103 04-24-96 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 I SKETCH: I I I , I V71, I I I I I I , I i , I Vd , I , I I , I I I I I I I , , I V5 ' I I , , I , , , I 24 I I I 6 V4' S/R 24 I I , , I , , I 1 I I I 3 W/B I I I V31 I I I I I , i 1 I I I , V2 I I I i I I I I I I I I I , i t , I Ice plant 2 I i I Concrete wall Steel guard rail ; ; V1 f— and Chain-linked I Fence I I I Asphalt 5noulaer Asphalt Shoulder W4 W3 W2 W Asphalt roadway 6'0" 12'0'* 12'0"_ 12-0" 12'0" I ' i PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 STATE OF CALIFORNIA _ NARRATIVE/SUPPLEMENTAL PAGE DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 1 DIAGRAM: V N •::I,: 1 24 S/R 24 3 V V/U 2 Ice plant Concrete wall 4— and Chain-linked Steel guardrail ', ; Fence ._. . Hv 1 � ' Asphalt Shoulder Asphalt Asphalt roadway Shoulder W4 W3 W2 W1 6'0" 12'0" 12'0" 12-0" 12'0" 6 0" 2 I - PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE e K CRANE 010103 04/24/96 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE /o DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 1 LEGEND: 2 3 VEHICLE POINTS SOF REST: 4 5 VEHICLE# DIRECTION REFERENCE DIRECTION REFERENCE 6 7 V-1 LIF WHEEL 14 ft N/S/RDWY EDGE S/H 24 WB - 60ft E/E/EDGE I-580 OIC 8 V-1 LIR WHEEL 14 ft NISI " " - 69ft " " 9 V-2 LIF WHEEL 14 ft NIS " " - 85 ft " " 10 V-2 LIR WHEEL 14 ft NIS " " - 94 ft " " 11 V-3 LIF WHEEL 20 ft NIS - 90 ft 64 " 12 V-3 LIR WHEEL 19 ft NIS " " - 100 ft " " 13 V-4 LIF WHEEL 24 ft NIS - 106 ft 66 14 V-4 LIR WHEEL 22 ft NIS - 115 ft 15 V-5 LIF WHEEL 19 ft N/S - 124 ft " 16 V-5 LIR WHEEL 18 ft NIS " - 133 ft 17 V-6 L/F WHEEL 17 ft NIS " - 140 ft 18 V-6 LIR WHEEL 16 ft NIS - 149 ft 19 V-7 LIF WHEEL 15 ft NIS 155 ft " 20 V-7 L/H WHEEL 15 ft NIS " - 165 ft 21 22 23 PHYSICAL EVIDENCE: 24 25 L Miscellaneous Vehicle parts and lens debris. I - F t a PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 1 FACTS: 2 3 NOTIFICATION: I responded to a radio call of a traffic collision with no details from 4 Golden Gate CHP Communications Center at 0759 hours from I-80 WB at University Ave, 5 and arrived on scene at approximately 0811 hours. All times, speeds and measurements in this 6 investigation are approximate. Measurements were taken by pacing and/or estimation, except 7 where otherwise indicated. 8 9 SCENE: At the scene of this collision, S/R 24 is a westbound freeway in the city of 10 OAKLAND, consisting of four lanes. The roadway is straight and mostly level. The surface is 11 composed primarily of asphalt. The roadway is bounded on the North by an asphalt shoulder, 12 berm and steel guard rail and on the south by an asphalt shoulder, dirt shoulder and concrete 13 wall and chain linked perimeter fence . See diagram. 14 15 PARTIES: 16 17 Pari # 1 (Godinez) was located S/R 24 WB by V-1. Party Godinez was identified by a valid 18 California driver's license. Godinez was placed as a party by the following items: 19 -personal statements 20 - location 21 -being registered owner 22 - being in possession of the vehicle's keys 23 24 Nissan Pathfinder,Driver# l's vehicle, was located on its wheels as shown on the diagram. 25 V- 1 sustained Minor damage, including: 26 - rear bumper and tailgate area. 27 28 No prior defects were noted or claimed 29 30 Party #2 ( ogard) was located S/R 24 WB in Vehicle 92. Party Bogard was identified by a 31 valid California driver's license. Bogard was placed as a party by the following items: 32 -personal statements 33 - location 34 -being registered owner 35 -being in possession of the vehicle's keys . 36 37 38 39 40 PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE Z DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 1 Acura Integra, Driver# 2's vehicle, was located on its wheels as shown on the diagram. V- 2 _ 2 sustained moderate #mage, including: 3 - front bumper 4 - front grill 5 - hood 6 -right rear quarter panel 7 8 No prior defects were noted or claimed. 9 10 Party#3 (Johns) was located s/r 24 WB by Vehicle#3. Party Johns was identified by a valid 11 California driver's license. Johns was placed as a party by the following items: 12 - personal statements 13 - location 14 - being registered owner 15 16 Ford Crown Vic, Driver# 3's vehicle, was located on its wheels as shown on the diagram. V- 17 3 sustained minor damage, including: 18 - left front fender 19 - rear bumper 20 21 No prior defects were noted or claimed. 22 23 Partes 9 4 (Tano was located S/R 24 WB in the L/F of Vehicle#4. Party Tang was identified 24 by a valid California driver's license. Tang was placed as a party by the following items: 25 -personal statements 26 - location 27 - injuries 28 - being registered owner 29 30 Geo Prizm, Driver#4's vehicle, was located on its wheels as shown on the diagram. V- 4 31 sustained moderate damage, including: ,. 32 - - front bumper 33 - front hood 34 - - front fenders 35 - rear bumper and taillight assembly 36 37 No prior defects were rioted or claimed. 38 PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE /3 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4=295 1 Parjy# 5 (Gill) was located S/R 24 WB in the L/F seat of Vehicle#5. Party Gill was 2 identified by a valid California driver's license. Gill was placed as a party by the following 3 items: 4 - personal statements 5 - location 6 -being registered owner 7 - being in possession of the vehicle's keys 8 9 Dodge Diplomat, Driver# 5's vehicle, was located on its wheels as shown on the diagram. V- 10 5 sustained minor damage, including: 11 - front bumper 12 - right front fender 13 -rear bumper 14 15 No prior defects were noted or claimed. 16 17 Party # 6 (Tavenier)was located S/R 24 WB by Vehicle #6. PartyTavenier was identified by 18 a valid California driver's license. Tavenier was placed as a party by the.following items: 19 - personal statements 20 - location 21 -being in possession of the vehicle's keys 22 23 Chevy Corsica, Driver# 6's vehicle, was located on its wheels as shown on the diagram. V- 6 24 sustained moderate damage, including: 25 - front bumper 26 - right and left rear quarter panels 27 - rear trunk area 28 29 No prior defects were noted or claimed. 30 31 Party#7 (Boehmer) was located S/R 24 WB in the L/F of Vehicle 47. Party Boehmer was 32 identified by a valid California driver's license. Boehmer was placed as a party by the _ 33. following items: . 34 -personal statements -- 35 - location 36 - being in possession of the vehicle's keys 37 38 39 40 PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE /y DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 1 Ford F250, Driver# 7's vehicle, was located on its wheels as shown on the diagram. V- 7 2 sustained,moderate damage, including: 3 - front grill 4 - front bumper 5 -hood 6 7 No prior defects were noted or claimed. 8 9 10 PHYSICAL EVIDENCE: 11 12 DEBRIS: 13 There was miscellaneous vehicle parts and lens debris located in the number 2 lane of S/R 24 14 WB. (See diagram). 15 16 STATEMENTS: 17 18 Party# 1 (Godine4 stated that: 19 I was driving westbound on S/R 24 at about 50-55 mph, in the 42 lane.-Traffic ahead began to 20 stop and I saw 2 cars ahead of me collide. I stopped behind them and I looked in my rear view 21 mirror and saw V-2 stop behind me. I then saw V-3 approach and collide with V-2 knocking 22 him forward into the rear of my vehicle. 23 24 Party#2 (Bogard) stated that: 25 I was driving westbound on S/R 24 at about 50-55 mph, in the #2 lane behind V-1. V-1 stopped 26 and I stopped behind him. I was immediately rear ended by V-3 and pushed forward into the 27 rear of V-1. 28 29 Party#3 (Johns) stated that: - 30 I was driving westbound on S/R 24 at about 50-55 mph, in the #2 lane behind V-2. I saw V-1 31 and V-2 stopping for traffic ahead and I attempted to stop also. I applied the brakes and began 32 sliding and tried to swerve to the right to avoid V-2 but was unsuccessful and hit V-2 knocking 33 him forward into V-1. I was then immediately rear ended by V-4. 34 35 Party#4 (Tana) stated that: 36 I was driving westbound on S/R 24 at about 50-55 mph, in the 42 lane 20 yards behind V-3. I 37 saw the cars slowing and I also began to slow. I saw V-3 hit the rear of V-2 and I applied my 38 brakes but the car slid into V-3. I was then hit from the rear by V-5. 39 I - 40 { - i 1 PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 j 'STATE OF CALIFORNIA NARRATIVEISUPPLEMENTAL PAGE /-5 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 1 Party# 5 (Gill) stated that: 2 I was driving westbound on S/R 24 at about 50-55 mph, in the#2 lane behind V-4. I saw the 3 collision ahead and I stopped behind V-4 and I was immediately hit from the rear by V-6 and 4 pushed forward into V-4. 5 6 Party # 6 (_Tavenier) stated that: 7 I was driving westbound on S/R 24 at about 50-55 mph, in the #2 lane behind V-5. I saw traffic 8 ahead stopping and I stopped behind V-5. I was then rear ended by V-7 and pushed forward 9 into the rear of V-5. 10 11 Party# 7 (Boehmer) stated that: 12 I was driving westbound on S/R 24 at about 50-55 mph, in the #2 lane quite a distance behind 13 V-6. I saw traffic ahead stopping and colliding with each other and I applied V-7's brakes and 14 tried to swerve to the left but V-7 want straight and slid into the rear of V-6. 15 16 17 OPINIONS AND CONCLUSIONS 18 � 19 SUMMARY: 20 D-1 (Godinez) was driving V-1 (Nissan Pathfinder), westbound in the #2 lane of S/R 24 at 21 approximately 50 mph. D-2 (Bogard) was driving V-2 (Acura Integra), westbound in the 92 22 lane of S/R 24 at approximately 50 mph. behind V-1.D-3 (Johns) was driving V-3 (Ford Crown 23 Vic), westbound in the#2 lane of S/R 24 at approximately 50 mph. behind V-2. D-4 (Tang) 24 was driving V-4 (Geo Prizm), westbound in the #2 lane of S/R 24 at approximately 50 mph. 25 behind V-3. D-5 (Gill) was driving V-5 (Dodge Diplomat), westbound in the #2 lane of S/R 24, 26 at approximately 50 mph. behind V-4. D-6 (Tavenier) was driving V-6 (Chevy Corsica), 27 westbound in the#2 lane of S/R 24 at approximately 50 mph. behind V-5. D-7 (Boehmer) was 28 driving V-7 (Ford F250), westbound in the #2 lane of S/R 24 at approximately 50 mph. behind 29 V-6. P-1 stopped for traffic ahead and a traffic collision that had just occurred. P-2 stopped 30 behind V-1. P-3 was unable to stop and overtook and collided with V-2 propelling V-2 forward 31 into V-1. P-4 was unable to stop and rear ended V-3. P-5 stopped behind V-4. P-6 stopped 32 behind V-5. P-7 was unable to stop and rear ended V-6 propelling V-6 forward into V-5 which 33 propelled V-5 forward into the rear of V-4. 34 The summary is based on the statements of the available involved parties, physical evidence, 35 and my observations. 36 37 38 39 40 PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE 16, DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 04/24/96 0755 9370 010103 4-295 1 POINT(S) OF IMPACT (POI . t 2 The initial POI between V-3 and V-2 was located 100 feet east of the east edge of the I-580 3 O/C and 20 feet north of the south roadway edge of S/R 24 WB. POI #2 between V-2 and V-1 4 was located 86 feet east of the east edge of I-580 O/C and 18 feet north of the south roadway 5 edge of S/R 24 WB. POI #3 between V-4 and V-3 waslocated 112 feet east of the east edge of 6 the 1-580 O/C and 21 feet north of the south roadway edge of S/R 24 WB. POI #4 between V-7 7 and V-6 was located 157 feet east of the east edge of the I-580 O/C and 18 feet north of the 8 south roadway edge of S/R 24 WB. POI #5 between V-6 and V-5 was located 142 feet east of 9 the east edge of the I-580 O/C and 20 feet north of the south roadway edge of S/R 24 WB. POI 10 # 6 between V-5 and V-4 was located 127 feet east of the east edge of the I-580 O/C and 22 feet 11 north of the south roadway edge of S/R 24 WB. 12 13 CAUSE: 14 The cause is based on the statements of the available involved parties, physical evidence, and 15 my observations. Party 3.is Primary cause of this collision in violation of 22350 V.C. - Unsafe 16 speed for conditions, overtaking and colliding with V-2. Party 4 and Party 7 are associated 17 causes of this collision also being in violation of 22350 V.C. -Unsafe speed for conditions, 18 overtaking and colliding with stopped traffic. Parry 2 is in dation of 16025 (a.2) V.C. -No 19 proof of financial responsibility in Vehicle#2. 20 21 RECOMMENDATIONS 22 23 None. I - PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE K CRANE 010103 04/24/96 FULL:SERVICE-DAMAGE &EVALUAION-AUTOS,TRUCKS, HEAVY&FARM EQUIPMENT &BOATS Servicing San Jose-Santr`lana, San'Mateo, Alameda&San Franc N Counties ROBERS-ON. : ;A:P_P:RAISAL. .ASSOCIATES N < 769.COVINA WAY `FREMONT, CA::-94539,' r DATE: qL INSURED CO.-CLAIM �.. f r �4 � ,.,ASSN FILE+� ., t , CLAIMANT: APPRAISER: r ' . - •,-: .),$�+ti.'itt rt.: :rcytJ`` �.i.n 'n.fr ste'-� G_�. r. '. -. MAKE . : :YEAR;:: MODEL-,,::,:z•x, . >;: BODY.SYLE:.: I D NUMBER . LICENSE# MILEAGE ��c► ; 1g3i.--73 9 R FLA ALL'D P P DETAILS OF REPAIR AND REPLACEMENTS `^ x ' PNT RAT LBR PARTS OR . SUBLET R L -HRS 'HRS HRS MATERIAL .� 'C i W , �h "V! '7. iR E ,7 s�-•'u ate;l .t. r5 ' 1-b &�y� - J 7i?t r.t.,: ,� 3.Y,fi. s "ilF..q.'• �a s x /fir. 10 lob • 14 (o ► , . r . oK� l� S / t vo 10 .2 r- 66T THIS IS NOT A REPAIR AUTHORIZATION AUTHORIZATION MUST SE SECURED FROM OWNER OF VEHICLE.;— . THIS DOES NOT ERIFY COVERAGE N AN AGREEME(PA AY PAY FOR REPAIR...: FOR$ LESS DED.'$ HE UNDERA LABO @ $ AGREES TO CO PLETEAND GUARA EE ALL LISTED R '_:;~`,^r< ;. PA S $ TO THEABOVE ED VEHICLE 4 N PARTS ' $ T @ COMPANY. SUB .. y::. ADV. ARGES $ ol ADDRESS: TOTAL S LESS B ERMENT $ BY: GRAND T TAL $ N PPLEMENTS OUT PRIOR P VAL . G , :..• ., FUI'L SERVICE-DAMAGE &EVALUAION'-AUTOS.TRUCKS, HEAVY&FARM EQUIPMENT&BOATS ' Servicing San Jose-Sanj ^.lara, San Mateo,-'Alameda&San Fran o Counties' §. ;:k�' rj`.i;:i`�.r- r-3'-.��'t�:.t"t qs�.::�pmt�.i s 1 x�,.!�! a `-.� •i:..... .. - ,' R0BER.S.0W.,ARPRAtSAL ASSOCIATE S • ,s , y ` 1 FREMONT,°CA'94639 j4 {•DATE: �� '(510)'6t6-2123 �.�„�,1r s 1.i.."k nT T yf r•+.e .� ���'�; F<S tom.' p' �,t. •. ' = rft'' �'' t ,'•. Y:. INSURED: ��` r �V Lis, f CO..CLAIM s raj } ASSN FILE# CLAIMANT: r 7 `APPRAISER: v MAKE YEAR 'c MODEL. ::f^:mss: BODY. I D UMBER LICENSE MILEAGE &6 c ar "T IOL� �'�tuA�30 R R' FLA ALUD P P: DETAILS OFAEPAIR ANDREPLACEMENTSS PNT .RAT LBR PARTS OR SUBLET R L, HRS HRS HRS MATERIAL • 77-7 iv THIS IS NOT A REPAIR AUTHORIZATION , • .? �. a AUTHORIZATION MUST BE SECURED"FROM OWNER OF VEHICLE THIS DOES NOT VERIFY COVERAGE NOR AN AGREEMENT•TO PAY PAY.FOR REPAIR t Y _ 110 FOR J SS DED.'l LL//� THELUNDERSIGNED LABOR 4 : f �l I J► C/U _ . AGREES TO COMPLETE AND GUARANTEE ALL LISTED REPAIRS i `` 'PARTS $ 1� TO THE ABOVE LISTEDVE E NET PARTS S S •? AX COMPANY:. t SUBLET S F . .ADV. CHARGES S ' ADDRESS: s TOTAL $ r;. LESS BETTERMENT S BY: ' GRAND TOTAL $7176 •JS NO SyiDPLEMENTS WITHO PRIOR APPROVAL FULL SERVICE DAMAGE.&EVALUAION AUTOS,'TRUCKS, HEAVY b FARM EQUIPMENT &BOATS . �)\/{�//�� Servicing San Jose tiara, San Mateo,Alameda-&San Franc .o Counties ROBE'RSON:.: A.P.PRAISA.L ::. ASSOCIATES 769 COVINA WAY.t i gyp' � ' rr? i ,. ' _t JJ'•fY"� � �.• � 'G - ..FREMONT,CA .DATE: , ���'. f'. _ t<- '-''sSi r:'t�i •:�7F•1Sv , �M j r•,. r;v ..i i}3 A - INSURED: � �i ; V1/I x ;� 'i ��r r CO. CLAIM �i /9-w • -.t "' s•�< C r , ; ,�, , K ,i � ,, r, kASSN FILE� - 7 CLAIMANT: �t `Fs ` �R APPRAISER: ►. 6Q MAKE YEAR MODEL--,..:.k-1..*. : :BODY SYLE. -� -.: .i D NUMBER LCE SE MILEAGE r r C1 R R k FLA ALL'D P P DETAILS OF REPAIR AND REPLACEMENTS; f PNT, ;RAT LBR PARTS OR SUBLET. R L <::: N,, �.4: :; : .: r• . HRS HRS HRS MATERIAL aw AA t ' r . - i '•:,fie '•:�: -. :.. ;.:THIS IS NOT.A REPAIR A HORIZATION AUTHORIZATION MUST BE SECURED FROM OWNER OF VEHICLE THIS DOES.NOT VERIFY COVERAGE NOR AN AGREEMENT,TO PAY PAY FOA REPAIR 1 . FOR S ' " LESS DED.'S THE UNDERSIGNED •_,k` LABOR @ f Vim' D•�/!/ ' "'- AGREES TO COMPLETE AND GUARANTEE ALL LISTED REPAIRS _ ".!.. PARTS •. ' $ •'- ' TO THE ABOVE LISTED VEHICLE r 1 NET PARTS S E n 5 TAX @ . - COMPANY `• - ' , T% SUBLET S - ADV. CHARGES $ ADDRESS: . .' , TOTAL , .' S LESS BETTERMENT S BY: GRAND TOTAL $ NO SUP LEMENTS WITHOUT RIOR APPROVAL Q � • `�� AL1, 1 DATE DESCRIPTION WIA 11"SON RAINNO MAINE W2911100 ZOO NO 000 M ONE 0 M11100 � _ MHOON0 ®10010■ �/1OI1 - " 1 i lJl�]�■ WA 001 � ��l���■ �■ .� _ _ , :. _ ,1J�! ,�1�!_A , :�. ■FNM■ WIAONEP�11 OW'* MINN.. 01101010 MA0101 MEMO WA 11OWN_ ME MAII1 FOR, 11000,6 13110111 1100 001 W. I I VI�, , MEMOFA W-1 ■ =Imams Bill 0011100�� ,.� �, Imo' ■�Ui■ m■m■m■ ■■m1100 MEMO ■ mm ■■■■■■M■ r. ■■■moms ■■� ■■■■■■■■■■ TOTAL PARTS h above is an estimate based on our inspection and does not cover any additional parts or labor av .► ® h:h (nay be required after the work has been started. Ouotations on parts and labor are current 11 TOTAL LABOR HRS. and subject to change, SUBTOTAL AUTm0;I-.'4",)N FOR REPAIR You are hereby authoriZed to make lhe above rocia-m TAX TOTAL SUBLET SIGNED 1 �■ UN 3 n rL � S 020 v m 2 r' r Nm OM 13 Nr 3 p1L 1 l•'J x Q• i � h ON l .. K K3 rr - 0t art W U QQ U" o . , Y. Sit ss � " AMENDED C L A I M BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA October 22, 1996 Claim Against the County, or District governed by) BOARD ACTION the Board cf Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board A:tion. 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 IY below), given pursuant t,�� Amount: $701000.00+ Section 913 and 915.4. Please note a arnings" CLAIMANT: Rodeo Sanitary District OCT 0 8 1996 COUNTY COUNSEL ATTORNEY: David J. Levy, Esq. MARTINEZ CALIF. Schwartz, Levy & Lavin Date received ADDRESS: 2121 North California Blvd. , BY DELIVERY TO CLERK ON October 7, 1996 Suite 1010 Walnut Creek, CA 94596 BY MAIL POSTMARKED: October 4, 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 8, 1996 tell �apu ytoR, Clerl� I1. 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: k— f4 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). 1V. BOARD ORDER: By unanimous vote of the Supervisors present (x) 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: /0 ' 2t`9(o 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: AD' 2 " 9cv BY: PHIL BATCHELOR Deputy Clerk CC: County County Administrator SCHWARTZ.9 LEVY & LAVIN ATTORNEYS AT LAW A PROFESSIONAL ASSOCIATION 2121 NORTH CALIFORNIA BOULEVARD,SUITE 1010 WALNUT CREEK, CALIFORNIA 94596 (510)934-6082 FACSIMILE(5101 934-1507 MARCHMONT J.SCHWARTZ OF COUNSEL BEVERLY J.LAVIN October 4, 1996 DAVID J. LEVY KENNETH H.LAVIN CERTIFIED MAIL RETURN RECEIPT REQUESTED Clerk, Board of Supervisors 651 Pine Street Martinez, CA 94553 Re: Amended Claim of Rodeo Sanitary District Our File No. 602-003 Dear Sir: Enclosed for filing and presentation to the full Board of Supervisors please find the Amended Claim of Rodeo Sanitary District. Yours very truly, Schwartz, Levy & Lavin A Professional Association C�' David J. Le DJL/car Enclosure cc: Mr. Valentin Alexeeff, Director Contra Costa County Growth Management and Economic Development Agency Thomas B. Bruen, Esq. Bruen & Gordon 603-005/Supervisor/Itr/W L/car RECEIVED RODEO SANITARY DISTRICT Off ' 7 06 P. O. Box 97 Rodeo, CA 94572 CLERK8UPMV 1nA CONTRA COSTA CO. AMENDED CLAIM AGAINST COUNTY OF CONTRA COSTA To: The Honorable Chairman and Members, Board of Supervisors County of Contra Costa State of California Rodeo Sanitary District hereby makes claim against the County of Contra Costa for a sum in excess of Seventy Thousand Dollars ($70,000.00) and makes the following statements in support of the claim: 1. Claimant's post office address is: Rodeo Sanitary District P. O. Box 97 Rodeo, CA 94572 2. Notices concerning the claim should be sent to: David J. Levy, Esq. Schwartz, Levy & Lavin 2121 North California Boulevard, Suite 1010 Walnut Creek, CA 94596 3. The date and place of the transaction giving rise to this claim are as follows: Effective on August 5, 1996, the Board of Supervisors -ranted exclusive garbage franchise rights to Pleasant Hill Bayshore Disposal, Inc., for the area in Contra Costa County that is entirely within the Rodeo Sanitary District. 4. The circumstances giving rise to this claim are as follows: Rodeo Sanitary District (herein referred to as Rodeo) is an autonomous special district in Contra Costa County, California, created pursuant to the Sanitary District Act of 1923 with the I 602-005/Claim/Amd/WL/car full statutory authority to collect waste and garbage within the District and to enter into contracts for the collection and disposition of garbage. For over forty (40) years, Rodeo has administered, set rates and supervised the collection and disposition of garbage within the District by entering into an exclusive garbage franchise with a qualified contractor. Pleasant Hill Bayshore Disposal, Inc., has an exclusive garbage collection franchise within Rodeo Sanitary District through and including October 31, 2001 whereby Rodeo is paid a franchise fee of four percent(4%) of garbage rates that are collected within the District. The funds collected as franchise fees are for the express purpose of defraying costs, attorney fees and liability resulting from Acme Landfill's litigation to close the garbage landfill. On August 23, 1996, Pleasant Hill Bayshore Disposal, Inc., informed Rodeo Sanitary District that the County of Contra Costa entered into a written exclusive franchise agreement with Pleasant Hill Bayshore Disposal, Inc., for the collection of solid waste within the area of Rodeo. Said agreement provides on its face to be effective in Rodeo Sanitary District area on August 6, 1996. On October 3, 1996, the Secretary of Rodeo telephoned Pleasant Hill Bayshore Disposal, Inc., and asked for the payment of the franchise fee that was due on September 30, 1996, from Pleasant Hill Bayshore Disposal, Inc., to Rodeo. The representative for Pleasant Hill Bayshore Disposal, Inc., stated that it was awaiting instructions from Contra Costa County. Without the concurrence or approval of Rodeo, the County of Contra Costa acting through its Board of Supervisors knowingly and willfully tortiously induced Pleasant Hill Bayshore Disposal, Inc., to breach its exclusive contract with Rodeo and to enter into an exclusive agreement with Contra Costa County for a garbage collection franchise within the same area of Rodeo Sanitary District. 2 602-005/Claim/Amd/DJUcar 5. Claimant's claim is in an amount that would place it within the jurisdiction of the Superior Court. 6. The name of the public employee who is most knowledgeable about this claim is Val Alexeeff. Dated: October , 1996 Rodeo Sanitary District By David 3. Le as Atto ey for Rodeo Sanitary Di ict 3 602-005/Claim/Amd/Mcar N A z C1 z � x ^ n 9 � t n r O a x A SA � n D Z tin rI f p D Or W; m O •��1 z a i n t� i� LM w N � p Co 0 W C4 ^s C O C. APPLICATION TO FILE LATE CLAIM October 22, 1996 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTION Application to File Late Claim ) NOTICE TO APPLICANT Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4• Please note the "WARNING" below, Claimant: Shariar Kovassi �•r(�"�8��� Attorney:Smith & Burstein OCT 10 1996 Jack B. Burstein SBN 26464 Address: 1730 Sonoma Blvd. , P.O. Box 7026 MARTINEZ CALIFL Vallejo, CA 94590 Amount: $200,000.00 By delivery to Clerk on October 9, 1996 Date Received: October 9, 1996 By mail, postmarked on Hand Delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: October 10, 1996 PHIL BATamm, Clerk, Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6). (� The Board should deny this Application to File Late Claim (Section 911.6). DATED: VICTOR WESTMAN, County Counsel, By aX,0 Deputy III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6). (x) This Application to File Late Claim is denied (Section 911.6). I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATE: io- z� —9'Cv PHIL BATCHELOR, Clerk, By - /, ' R� Deputy WARNIM (Gov. Code S911.8) If you Wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed With the court Within six (6) months from the date your application for leave to present a late claim Was denied. You may seek the advise of any attorney of your choice in connection With this matter. If you Want to consult an attorney, u should do so immediately. V. FROM: Clerk of the Boar T0: 1 County Counsel 2 County Administrator Attached are copies of the above Application. We notifed the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has ben filed and endorsed on; the Board's copy of this Claim in accordance With Section 29703. DATED: /� ` 2 5-qC� PHIL BATCHELOR, Clerk, By 67) Deputy V. FROM: 1 County Counsel 2 County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM ' RECEIVED :per - 91996 'V,`/7 /-?M ' CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. SMITH & BURSTEIN Jack B. Burstein SBN 26464 1730 Sonoma Blvd. , P.O. Box 7026 Vallejo, CA 94590 (707) 643-8405 Attorneys for Claimant, SHARIAR KOVASSI Re: Application for Leave of File. October 9, 1996 LATE CLAIM To: The County of Contra Costa The Board of Supervisors, County of Contra Costa Shariar Kovassi requests leave to present a late claim, based upon the following facts: a. Claimant was damaged within six months last past as a result of the dissemination of certain psychological test results and psychological analysis relating to the claimant obtained in conjunction with a custody proceeding to which claimant was not a party. b. Attached hereto as Exhibit "A" is a proposed claim that claimant desires to present to the County of Contra Costa. C. The basis for the claim being late is that although it is believed that the claim did not arise until within six months of October 9, 1996, in the event the initial dissemination of April 8, 1996 is the date upon which the time for filing a claim commenced, then, the failure to file on or before October 8, 1996, was through inadvertence and excusable neglect, in that it was believed that the person who disseminated the information was acting in a capacity other than as in the capacity of a Special Master in the custody proceedings that are the subject of the proposed claim. WHEREFORE, claimant requests that his application for leave to file a late claim be granted. �6 MITH & BURSTEIN B J CK B. BURSTEIN 2 RECEIVED i� -9 1996 SMITH & BURSTEIN V;17 '��' Jack B. Burstein SBN 26464 CLERK BOARD OF SUPERVISORS 1730 Sonoma Blvd. , P..O. Box 7026 CONTRA COSTA CO. Vallejo, CA 94590 (707) 643-8405 Attorneys for Claimant, SHARIAR KOVASSI October 9, 1996 To: The County of Contra Costa The Board of Supervisors, County of Contra Costa Shariar Kovassi hereby presents his claim against the County of Contra Costa for damages arising as the result of statements made and publicized 'by�County of Contra Costa, acting through its special master, one, Thomas H. McCord, Ph.D. The actions of, Thomas H. McCord, Ph.D. , consisted of disseminating information relating to Psychological Reports and evaluations of claimant in connection with a pending custody proceeding, to which claimant was not a party. Said dissemination and injury to claimant occurred within six months last past. Said actions constitute an invasion of privacy and caused emotional distress entitling claimant to general damages in the sum of $150, 000. 00 and, punitive damages in the sum of $200, 000. 00. Executed at Vallejo, California, this , day of October, 1996. SMITH & BURSTEIN CK B. BURSTEIN SMITH & BURSTEIN Jack B. Burstein SBN 26464 1730 Sonoma Blvd. , P.O. Box 7026 Vallejo, CA 94590 (707) 643-8405 Attorneys for Claimant, SHARIAR KOVASSI October 9, 1996 To: The County of Contra Costa The Board of Supervisors, County of Contra Costa Shariar Kovassi hereby presents his claim against the County of Contra Costa for damages arising as the result of statements made and publicized by County of Contra Costa, acting through its special master, one, Thomas H. McCord, Ph.D. The actions of Thomas H. McCord, Ph.D. , consisted of disseminateing information relating to Phsychological Reports and evaluations of claimant in connection with a pending custody proceeding, to which claimant was not a party. Said dissemination occurred on April 8, 1996. Said actions constitute an invasion of privacy and caused emotional distress entitling claimant to general damages in the sum of $150, 000.00 and, punitive damages in the sum of $200, 000. 00. All notices shall be sent to the undersigned attorney at the above address. n ,t Executed at Vallejo, RCalifornia, this , day of October, 1996 SMITH & BURSTEIN BY: JACK BURSTEIN