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HomeMy WebLinkAboutMINUTES - 01062004 - C22 CLAIM �'j�G.�r BOARD OF S RVISO_RS OF CONTRA COSTA COUNTY BOARD ACTION* JAN' 06, 2004 Claim Against the County, or District Governed by ) 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 California Government Codes. ) notice of the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), give: Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $100.00 CLAIMANT: HAZEL J. GRENIER ATTORNEY: UNKNOWN DATE RECEIVED: DEC• 01 , 2003 ADDRESS: 268 KAWAIT WAY BY DELIVERY TO CLERK ON: DEC. 01, 2003 PACHECO, CA 94553 BY MAIL POSTMARKED: HAND DELIVERED BY RISK. MANAGEMENT FROM: Clerk of the Board of Supervisors TO County Counsel Attached is a copy of the above-noted claim. , Clerk Dated: DECEMBER 01 , 2003 By: JOHN SW EDeputy II. FROM: County Counsel TO: Cleric of the Board of Su ervisors QJ This claim complies substantially with Sections 910 and.5�10.2. { ) 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: Dates: By: � _ � � Deputy county Couns, III. FROM: Cleric of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV./BOARD ORDER,: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date, Dated:\/4 JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code secti n 913) Subject to certain exceptions, you have only six (6) months from the date this ndtice was personally served or deposite 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: JOHN SWEETEN, CLERIC By Deputy clerk Claim to: BOARD OF SUPERVISORS OF Cl7NTRA COSTA COUNTY INSTRUCTIONS TO CLADiANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for.death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its ,off ice in Rex 106, County Administration Building, 851 Pine Street, Martinez, CA 94553• . C. If claim is against a district governed by the Bogard 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 b-- filed efiled against each public entity. E. ` Fraud. ,See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this farm. RE: Cl im By ) Reserved for Clerk's filing stamp RECEIVED Agai.n.sth Counnty of Contra Costa DEC 0 12003 or CLERK BOARD OF SUPERVISORS D str t� CONTRA COSTA Co. Fill in nam ° ) The undersigned claimant hereby makes, clai against the County of Contra Costa or the above—named 'District in the sum of $ 10G e 0 and in support of this claim represents as follows: 1. When did the dao ge or injury occur? (Give exact date and hour) z-' ' 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details, ae extra paper if required) �' rr 1 _ d `le 4. What particular act or omission on the part f county or district officers, servants or .emplo ;e.es caused. the.in ury or damage? ; r'" 5A1 � Ons y + ,� � ' 7. what are the names of county or district officers, servants or employees causing the damage or injury? 6. What darrage or injuries do you claim resulted? (Give full extent of i ,juries or damages claimed. Attach two estimates estimaattyes fore/auto damage. ,1� f v 1ff%�11 ale' Haw was the amount claimed a�computed? (Include the estimated amount of any 7. f prospective injury or damage.) � ddh Id1,e4 _.. . -Names------ rand-ad resses of witnesses, doctors and hospitals. 9. List the expenditures ynue_on a;coup of this AMOOUNT t or injury DATE ITEM Gov. Code Sec. ,910:2 provides: "The claim must be signed by the claimant SEAID NOTICES T0: (Attorney or some person -on his.behalf." Name and Address of Attorney aia;ant's Signature Address Telephone No. ;7 Telephone No. *p* * * +� 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 imprisor;ment in the county jail for a period of not more than one.year t by a fine of not exceeding one thousand ($11000), or by both such. imprisonment and fine-2-or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,0013, or by both such imprisonment and fine. California State P.C. Box 920 9359879 Aut6mobile Association Suisun City, CA 94585-0920 Inter-Insurance Bureau CHECK NO.: 708 L923487-7—R DATE: 10-01-2003 NAME AND ADDRESS INFORMATION: HAZEL GRENIER 268 KUWAIT WAY PACHECO CA 94553 INSURED: GREN I ER,HAZEL;OR RONALD PAYMENT INFORMATION/DESCRIPTION: DATE OF LOSS: 09-02-03 CLAIM NO.: 06—T22905-9 CLAIMANT: GREN I ER,HAZEL;OR RONALD PAYEE: HAZEL GRENIER,OR RONALD AMOUNT: $75.00 IN PAYME�TO�F�: AR REMOVAL LESS $100 DEDUCTIB ADJUSTER: DEANNA BERGGREN ADJUSTER NO.: 30391 KIND OF LOSS: CPR 76810702 DETACH AND RETAIN FOR YOUR RECORDS F488i�(Sep 5998} � k CG CLAIM BOARD !2F§jJPERV1SQA§ OF CONTRA COSTA COUNT'S �. BOARD ACTIONr JANUARY 06, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICETO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), give Pursuant to Government Code Section 913 and 91 . Please note all"Warnings". AINIOUNT: $263 .81 - $338 .81 CLAIMANT. ELIZABETH FRIEDMAN ATTORNEY: UNKN0�7N DATE RECEIVED: DEC. 01, 2003 ADDRESS, 3118 PINE STREET, BY DELIVERY TO CLERK ON: DEC . 01 , 2003 ANTIOCH, CA 94509 Bir MAIL POSTMARKED; HAND DELIVERED BY RISK MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted clam. JOHN SW E , Clerk Dated: DECEMBER 01.1 2003 By: Deputy H. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and410.2. ( } 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: r By: ;` Deputy County Couns, ISI, FROM: Clerk of the Hoard TO: County Counsel (1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: . Ok g gafxzJOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(6)months from the date this adtice was personally served or deposite 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: . 100 LWC JOHN SWEETEN, CLERK By Deputy Clerk "� f . �� y _ ' v ; ., r= ' . # ' ,,.E��..� "� �`�f� #��^' '� } #Pmt'ar`f��t Claim to; BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS To CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before. December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its .office in Room 106, County Administration Building, 551 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Burd 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 env of this form. RE: Claim By ) Deserved for Clerk's 'filing stamp DEC 0 Against the County of Contra Costa } 200 or CLE APD()F SljpC District) Co. Fill in name The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of and in support of this claim represents as follows: 1. When did the doge or injury occur? (Give exact date and hour) ...4L 2. ere did the damage or i�juryoccur? (Include city an Jccxznty) t 3. How did 6e damage or injury cur? (Give full details; use extrar. . required_) y� y� �y (`y" j f&Y_./ L�..; �/ � f {�f ✓ t -� 6 l L/is�4 L L 64.., C•? Ye-( e ✓C t L/ < / ✓' } t ,# `""� ' ..iri:.��%...��i.L -�k_��»� ��° � �,,y��'r� 1.� � `� � � ��'`a�✓{..,f h`'��. G✓_ �s?,..•'�..-,.p''�;.✓ ` 3..y r1 s' �. yf _ 4. What particular act or omission on the part of county or district officers, servants or .emplojyees/c"aused- the injury or damage? ( � Vis.,, f 1 (over) 7. wnat are the names of county or district officers, servants or employees causing the damage or injury? � 7-1c vi 6. Shat damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. E Al ilz 7. How was the aunt claimed above computed? (Include the estimated amount of any prospective injury or damage.) f f t 1, ,`i/ /' .....-------..r--- 8. --8. Naves and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accent or injury: DATE ITEM Gov. Code Sec. 910.2 provides the claimant claim must be signed by SEND N(7TICES T0: (Attorne } or b some erson on his. behalf." Dame and Address of Attorney f -> Claimant's Signature Address Telephone No. Telephone Na NOTICE Section 72 of the penal Cade 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 g, is ipunishable eitheany rbyse �imprisorimenttin claim, bill, account, voucher, or writing, pby a not the county jail for a period of not more imptri aone ent eart and fine j�orebyf imprisonment In one thousand ($1,0x0), or by both the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. 07/15/03 14:44 FAX 5106340956 Q01 BAR* AM19741S M`I ,FAL 411' HT-925--634-13855 FAX: 925--6.34--9956 CA LIC.# 7712'41 C 1-1 ex-b w ACCGUkT AI L=NT f+URCHASE NO- 1 .: RDER NCS.: DATE >17� UC7T CUSTOMER STATE TAX 0A€XEMPT N6. CVSTO " t7ERAL TAX 6D.NU. ADV.C=E ISALESMANID. 10FIDERTAKENAY INSTALLED BY FeFCCCk[ER�AL�TAX J.D.Nd. rhl D��47.ir Y7� BILL TO: FRIEDMAN, ELIZABETH SOLD TO: 3118 PINE ST ANTIOGHz CA 94�f119 Wke985-367--9630 Hm:925-754-1683 INSURANCE OF LOSS INSURANCE CO. POLICY NO. INSU4LANCE CO, PHONE NO. CLAIM NO. CAUSE& POLICY NAME LOSS LOCATION AGENT NAMEVERIFIED RY AGENT PHONE DATE OF LOSS DEDUCTIBLE VEHICLE INFORMATION MAKE', T o e t a SEL P a s e a YEAR 1992 6S ago Lit'/ VEHICLE _ _. I.D.NO. Qty part Number Calor Adhesive Labor List Sell Total i F'Wee687 GS COM Green/Bl ue 10.00-clu 8 Dam 3.3H 35.1210 647.30 165.33 210.33 OtPart Number Descrilpticyll List Sell Total � WFS 687 Moulding 36.04 36.04 36.04 i AUTHORIZATION TO PAY I hereby authorize and arrkt rover the above-named Insurance company to fray this Invoics in full settlement,eat- isfaCtivn and discharge of all lose Under the above policy. Upon such paymeni.all rights I may have for claim and dernand for Was and damage described above against the above named Insurance company shall be thereby forever discharged, in the event that the above narned insurance company does not make timely and/or S u bt of a 1 246. 37 full payment of this!nice according to Its terms,#hereby accept rasporrsibif#y for such payment and agree to a. ".15% Tax 17. 44 pay all charges reflected on this ftwoloa to the above named glass company subject to and according to all terms and cor#ditlons on this Invoice. t ELMS Cp {�L ,yy y� a 263.81 Jul 15 03 02: 20p Dan f'lazzoncini 925-827-0322 P. 1 MAIN OFFICE III�I I r..w CONCORD ANTIOCH L.AFAYETT'E BENICIA 1325 GALiNDO ST (925)754.0795 (925)256-6446 (707)746-7604 CONCORD,CA 94520 ( FAX(925)827-0322925)827-4173 QUOTE ACCO,; WJUX NNG NT ORDER NO,- DATE /1512171 3 4$ Ci75TOrdER 57ATE TAX Ori EXEMPT NO. FMTOMER FEDERAL TAX I.D.NO. At}V_CGDE SAI..ESMA'41.D. 0ADER TAKEN SY INSTALLED 9V FEL?@qAL TAX 1.0,NO. 6MI95256 SILL TO: iZ h-M FP.EWbriAX SOLD TO: 3118 PINE STREET .Ae]�MOCH CA 945451 INSURANCE PROOF • INSURANCE CO, POLICY NO. INSURANCE CO. PHONE NO. CLAIM NO, CAUSE& POLICY NAME LOSS LOCATION AGENT NAME VERIFIED BY AGENT PHONE HATE OF LOSS DEOUCT113LE VEHICLE INFORMATION MAKE TOYOTA (MODEL PASE0 YEAR 1992 t70iaR8 2' C3t1v?yfEicFi LiGENSiE •VEHICLE I.D.NO. Qty Th+eomr T1 rietiipt+talu TAX lid Dixc-Ilyi► Not TOW 1 FQV"60 HB jr:(P-0 T 647.30 68. 207.14 WT-14 1 C # N 55,00 35.00 55.00 HAH000004 T 19.00 19.C+{1 19.00 WFS 687 T 36.04 36.04 36.104 Properly cured sealants and/or,adhesives,and the`Autoglass are an important part of the safety feature of the vehicle,We at Clan's Glass,Inc>follow vehicle manufacturers recommondations on sealants and adhesives utilized in the Installation of the'Autoglass in your car.The cure time of the sealants or adhesives used are controlled by the climate(i.e.,weather)which could be 12 to 24 hours or more.Clan's Glass Inc.,dues not recommend you drive your car until the sealants and/ar adhesives used have cured proper+y.Guarantee against water leaks for the life of the car(except for rust or prior damage to glass area).Ban's Glass Inc.is not responsible for any damage to vehicle resulting from any water teak before or after glass work has been completed.This includes carpets,dash area,seats,etc. i + Rog.i=r*m Na. Data RELEASE AND AUTHOPJZATtON TO PAY OTHER THAN INSURED OR CLAIMANT 1.63 Tho alas*hes be en replaced to my satisfaction and f authorize to make direct payment to DAN'S GLASSo INC.the full amount!Sue me under the terms of my policy covering the said lass.I understand that if for any reason any insurance company diems riot pay this claim,t will be responsible for payment of sumo. In*woo-,_„ Date __ TM Wit f=SM OM To My SffOWMION--tVf MML NOT PHUPAMLE VATIMUT PWR A"111 iVAL CLAIM B ABDt OF.SUPERVI$QRS OF CONTRA COSTA COUNTY BCA ,CTIQNl -JAN. 06y_.2004 Claim Against the County, or District Caverned by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section reference: )` N The copy of this document mailed to you is your California Government Codes. ' notice of the action taken on your claim by the t r` Board of Supervisors. (Paragraph IV below), give: Pursuant to Government Code Section 913 and s °� 915.4. Please nate ail'Warnings". AMOUNT: $ UNLIMITED JURISDICTI0N CLAIMANT: JOHN TRAN AND NGUE MY VUONG ATTORNEY: ATTORNEY T. TROY OTUS DATE RECEIVED: DECEMBER 01, 2003 ADDRESS: LAW OFFICES OF OTUS & ASSOCIATES BY DELIVERY TO CLERK ON:DECEMBER 01, 2003 533 AIRPORT BOULEVARD, SUITE 505 BURLINGAME, CA 94010 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOSI SwEET N, C rk Dated: DECEMBER 021 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors KThis claim complies substantially with Sections 910 and.5J10.2. { ) This Claim PAILS 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: "B€ , Deputy County Couns( ISI. 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. ARD ORDER: By unanimous vote of the Supervisors present: W 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. JOIN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(6)months from the date this adtice was personally served or depositec in the mail to file a court action on this claim. See Government Code Section 945.6. You may seep 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: . f -" JOHN SWEETEN, CLERK By Deputy Clerk CLAIM BY ) RECEIVED ) John Tran and Ngue My Vuong ) DEC 0 1 2003 ISORS Against the County of Contra Costa ) TR,COSTACO or ) City of Martinez and City of Brentwood } The undersigned claimant hereby makes a claim against the County of Contra Costa or the above named District in the sum of$Unlimited Jurisdiction and in support of this claim represents as follows: 1. When did the damage or injury occur? June 2,2003 at approximately 15.30 p.m. 2. Where did the damage or injury occur? Walnut Boulevard and Vasco Road,City of Martinez and City and Brentwood,County of Contra Costa 3. How did the damage or injury occur? Claimant was involved in a serious automobile collision causing his death. Claimant contend that one of the causes of this accident was the negligent design,construction and maintenance of the involved roadway.Defendant's failed to implement any safety measures,redesign and/or modify the roadway,its signing and/or speed limit despite their knowledge that the involved roadway was dangerous and that numerous prior accidents have occurred in said area. 4. 'ghat particular act or omission on the part of the county or district officers,servants or employees caused the injury or damage? The area where the accident occurred is negligent designed,constructed,maintained and controlled.Defendant's failed to implement any safety measures, redesign and./or modify the involved roadway, its signing and/or speed limit despite their knowledge that the involved roadway was dangerous and that there had been numerous prior accidents in said area. 5. What are the names of county or district officers, servants or employees causing the damage or injury? County of Contra Costa,City of Martinez and City of Brentwood 6. What damages or injuries do you claim resulted?This involves a death case. General damages will be according to proof. Claimants son died as a result of this accident 7. Mow was the amount claimed above computed? According to proof 8. Names and addresses of witnesses, doctors and hospital? Discovery continues 3. List the expenditures you made on account of this accident or injury: Medical and burial expenses CLAIM ARD OF UPERYI ORS OF CONTRA COSTA COUNTY BOARD ACTION: JAN. 06, 20{3 Claim Against the County, or District Governed by ) 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 California Government Codes. notice of the,action taken on your claim by the Board of Supervisors. (Paragraph IV below), give: ' Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: UNKNOWN `s KATALIN RANKINS, INDIVIDUALLY AND ON CLAIMANT: BEHAT S OF HER MINOR SON HENRY RANKINS, III AND HENRY RANKINS, JR. ATTORNEY: JAMES J. O'DONNELL, ESQ. DATE RECEIVED: DECMBER 022 2043 ADDRESS: O'DONNELL & SMITH BY DELIVERY TO CLERK.ON: DECEMBER 02 2043 309 LENNON LANE, #101 WALNUT CREEK, CA 94598 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETS , 1 Dated: DECEMBER 02, 2003 By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ly,<This claim complies substantially with Sections 910 and 5.10.2. ( } This Claim FAILS to comply substantially with Sections 910 and 914.2, 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 971.3). ( } Other: VA Dated; By: '1LA CDeputy County Couns( 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). IVOARD ORDER.: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) {ether; I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: t,/rr. " 'JOHN SWEETEN, CLERK., By , Deputy Clerk WARNING (Gov, code sectio 913) Subject to certain exceptions, you have only six (6) months from the date this ndtice was personally served or deposite+ 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: Vk,," tl +G JOHN SWEETEN, CLERK By Deputy Clerk Claire to: BOARD CF' SUPERVMM OF CONTRA CX757A COUNTY INS- tGCTTONS TO CLAIMANT A. Claims relating to causes of action for death or for irju:•y to person or to per- sonall property or gmwing crops and which accrue on or before December 31, 1957 must be presented not later than the 100th clay after the acvrual of the cause of action. Claims relating to causes of.action for death or for injury to person or to personal property or growing comps 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 rather cause of action must be presented not later than one.yeas after the accrual of the cause of actio n. (Govt. Code B. Claims =:st be filed with the Clerk of the Board of Suvervis= at its office ir. z� Roan 105, County Administration Building, 651 Pine Stet, Martinez' CA 94553. C. If claim is against a district gover-ned. by the $card cif Supery.sors, rather th..=n t::e Coin y, tete name of the Hzt.�^ict should be filled ire. D. if the ciai.n is against more t2-n one public entity, sepa-mate cL ims must filed apinst each public ent;LL. E. Fraud. See penalty for fraudulent claims, Penall. Code Sec.. 72 a;, the end of this forsa. It RE: Claim 3y Ratalin Rankins, Rese_ :or Clerk's filing staWp individually and on behalf of her } minor son Henry Rankins, TT. anci ) rC1 !� Henry Rankins, Jr. RECEIVED Against the County of Contra Cos } or DEC 4 2 2003 District) FCLERK BOARD of SUPERVISORS Fill in name } CONTRA COSTA Co. The undersigned claimaat hereby makes claim against the County of Ccntra. Costa or the above- a d District in the sum of $ * and in support cf this claim represents .as follows-. *Venue Unlimited Juri4diction SuPe l r...Court 1. When did the aan or injury occ=? (Give exact date and hour) .am to. .1.:.0-0. P m _._ 2. Where did tae or injury occur? (Include city and county) Contra Costa County Regional Center _ 2500 Alhambra Ave. , Martinez, Ca {Contra Costa County_L_ 3. How did the dame or is jury occur? (Give full details; use extra ;oa.per if reguirsed) See Exhibit 1 attached hereto 4. What Yparticular act or omission on the part of county or district officers, servan is or .employees caused, the,injury or damage? See Exhibit 1 attached hereto.. 20'd 7uioi wrtat are t37e rAmes of co=ty or district officers, servants or employees causing the loge or injury? Various employees and agents of the Contra Costa Medical Center. 5. Wray damage or injuries do you claim resulted? (Give full extent of injuries or damases clamed. Attach two estimates for auto damage. See Exhibit 1 attached hereto 7. Fow was the amount claimed above computed? (Lncl.ude the estimated amunt of any prospective injury or damage.) See Exhibit 1 attached hereto. Damages to be determined by trier of fact . Na-es and addresses of wit-nesses, doctors and. hospitals. Done other than those medical care providers identified in claimants ' medical charts at Contra Costa Regional Medical Center 9. List the expenditures you made on acoount of this accident or inj,.:ry: DA TS ITS AI�C7L1�€T See Exhibit 1 attached hereto GoNi. Cade Sec. 910.2 provides: ffThe claim must be signed by the cl..aiaw.^t SM NCTICES T0: (Attorney) or by some person on �." Name and Addrew of Attorney /7 James J. Q'Donnell,Esq. Uj) Signattre O`DbNNELL & SMITH _ 3019 Lennon, Lane, #101 309 Leflaimarlt's on .Lane" Suite 101 Walnut Creek, Ca 94598 Address -- Walnut Creek, Ca 94598 Telephone No. 925J935-1707 Telephone No. 95/935-1707 �t �t N O T I C E Section 72 of the Pen-al Code provides: "Every person Who, with, intent to def ud, presents for allowance or for payment to any state bcard or officer, or to any county, city or district board or officer, authorized to allow or gray the same if.genuine, any fa.l.se or, fraud lent ciaim, bill, account, voucher, or twiting, is punishable either mp by iriscriz�nt 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' imp' risoriment and fine;,- or by imorisonment in the stave prise,:, by a fine of not exceeding ten thoasand dollary ($10,000, or by Z=hT EXHIBIT 1 Claim. of Katalin Rankins, individually At all times mentioned herein Contra Costa County was at all times and places mentioned herein engaged in the ownership,operation, and maintenance of hospitals and other medical facilities open to the general public and to patients in and about the State of California, including the County of Contra Costa. From on or about October 29, 2002 through June 3,2003,and for some time thereafter, Claimant Katalin Rankins consulted Contra Costa County and its medical care providers for the purpose of obtaining diagnosis, care, and treatment in connection with her medical conditions, including, but not limited to pregnancy, and employed them to examine, diagnose,treat,and care for said Claimant and her unborn baby. Centra Costa County undertook, individually and by and through its agents, servants and employees,to examine,diagnose, treat, prescribe for and care for Claimant Katalin Rankins and her unborn baby,including but not limited to examining, diagnosing,providing to and prescribing for and administering various drugs and medications and performing certain diagnostic tests and surgery,and did examine, treat,prescribe and care for Claimant Katalin Rankins and her unborn baby by means of various procedures, including but not limited to physical examinations, surgery, and the administration of certain drugs and medications. At all times and places mentioned herein Contra Costa County and its medical care providers carelessly and negligently instructed, examined,diagnosed, prescribed for, performed surgery on,cared for and treated Claimant Katalin Rankins and her unborn baby for their medical conditions, and provided hospital, medical, surgical,anesthetic,nursing, laboratory,x-ray, and ambulance services, care, and attention in a careless and negligent manner, and carelessly and negligently managed the medical care, surgery, and treatment, and carelessly and negligently failed to monitor and supervise the condition of the Claimant Katalin Rankins and the baby, and carelessly and negligently failed to administer appropriate care following surgery and to monitor, supervise and diagnose the condition of the Claimant Katalin Rankins and her baby, all of which, among other things,directly and proximately resulted in certain injury to Claimant Katalin Rankins and to the injury of her baby boy during her delivery of the baby, all to her general and special damage. As a direct and proximate result of said carelessness,negligence, acts, omissions and conduct of Contra Costa County and its medical care providers Claimant Katalin Rankins received certain and severe injuries, including but not limited to extensive and painful labor, delivery, injury to her baby boy, and injury to herself, resulting in impairment of mental and bodily function, and she has suffered and will continue to suffer great physical pain and mental suffering, and she has been impaired in her mental and physical capacity, all to her general and special damage in an amount in excess of the jurisdictional minimum of the Unlimited Jurisdiction of the Superior Court. As a direct and proximate result of said negligence, acts, omissions and conduct of Contra Costa County and its medical care providers, Claimant Katalin Rankins was required to and.did incur expenses for services of hospitals, doctors, and other medical care and treatment in an amount not now known to her, and Claimant is informed and believes and upon such information and belief alleges that she will incur additional expenses in the future in an amount not now known to her. Claimant Katalin Rankins is informed and believes and upon such information and belief alleges that she will suffer additional special damages in the future, including the inability to find employment, all these damages existing in a presently unascertained amount as such loss is not yet determined. As a further direct and proximate result of said negligence, acts, omissions and conduct of Contra Costa County and its medical care providers, Claimant Katalin Rankins was prevented from attending her usual activities and occupation, and Claimant Katalin Rankins is informed and believes and upon such information and belief alleges that she will be prevented from attending to her usual and anticipated activities and occupation in the future, all to her damage in an amount not now known to her, and plaintiff will ask leave of Court to amend her pleadings to set forth the exact amount thereof when the same becomes known to her. At all times mentioned herein, Claimant Katalin Rankins was and still is the wife of Claimant Henry Rankins, Jr. and was and still is the mother of Claimant Henry Rankins, RL Claimant Katalin Rankins was present during and following the medical and surgical care and treatment of her baby and observed and witnessed, at that time,through her oven sensory perceptions, the negligent conduct and omissions of Contra Costa County and its medical care providers which resulted in and were the proximate cause of the physical injuries to her new born son. Claimant Katalin Rankins observed the delivery of her son from her vagina and watched the injuries caused to her son as Contra Costa County and its medical care providers removed his body from her body. At all times herein mentioned, Claimant Katalin Rankins was a person to whom harm was reasonably foreseeable as a consequence of the existing parental relationship to her son. As a direct and proximate result of the aforesaid negligent conduct and emissions of Contra Costa County and its medical care providers, Claimant Katalin Rankins sustained great emotional disturbance and shock and injury to her nervous system,all of which have caused, continue to cause, and will cause her great physical harm and mental pain and suffering, and loss to her usual occupation, all to her general and special damage. At all tinges mentioned herein, Claimant Katalin Rankins was and still is the wife of Claimant.Henry Rankins, Jr.. As a direct and proximate result of the acts, omissions and conduct of Contra Costa County and its medical care providers, Claimant Katalin Rankins suffered the loss of support, services, love,companionship, affection, security, sexual relations and other elements of consortium, all to her general damage. 2 Claim of Katalin Ran-kins on behalf of her minor son Henry Rankins III At all times mentioned herein Contra Costa County was at all times and places mentioned herein engaged in the ownership, operation, and maintenance of hospitals and other medical facilities open to the general public and to patients in and about the State of California, including the County of Contra Costa. From on or about October 29, 2002 through June 3,2003, and for sometime thereafter, Claimant Katalin Rankins consulted Contra Costa County and its medical care',providers for the purpose of obtaining diagnosis, care, and treatment in connection with her medical conditions, including, but not limited to pregnancy, and employed them to examine, diagnose,treat, and care for said Claimant and her unborn baby. Contra Costa County undertook, individually and by and through its agents, servants and employees, to examine, diagnose,treat, prescribe for and care for Claimant Katalin Rankins and her unborn baby, including but not limited to examining, diagnosing,providing to and prescribing for and administering various drugs and medications and performing certain diagnostic tests and surgery, and did examine,treat, prescribe and care for Claimant Katalin Rankins and her unborn baby by means of various procedures, including but not limited to physical examinations, surgery, and the administration of certain drugs and medications. At all times and places mentioned herein Contra Costa County and its medical care providers carelessly and negligently instructed, examined, diagnosed,prescribed for, performed surgery on, cared for and treated Claimant Katalin Rankins and her unborn baby for their medical conditions, and provided hospital,medical, surgical, anesthetic, nursing, laboratory, x-ray, and ambulance services, care, and attention in a careless and negligent manner,and carelessly and negligently managed the medical care, surgery,and treatment, and carelessly and negligently failed to monitor and supervise the condition of the Claimant Katalin Rankins and the baby, and carelessly and negligently failed to administer appropriate care following surgery and to monitor, supervise and diagnose the condition of the Claimant Katalin Rankins and her baby, all of which, among other things, directly and proximately resulted in certain injury to Claimant Henry Rankins III during his delivery at birth, all to his general and special damage. As a direct and proximate result of said carelessness,negligence, acts, omissions and conduct of Contra.Costa County and its medical care providers Claimant Henry Rankins received certain and severe injuries, including but not limited to extensive and painful labor, delivery, injury to his body resulting in impairment of mental and bodily function., and he has suffered and will continue to suffer great physical pain and mental suffering, and he has been impaired in his mental and physical capacity,all to his general and special damage in an amount in excess of the jurisdictional minimum of the Unlimited Jurisdiction of the Superior Court. As a direct and proximate result of said negligence,acts, omissions and conduct of Contra Costa County and its medical care providers, Claimant Henry Rankins III was required to and did incur expenses for services of hospitals,doctors,and other medical care and treatment in an 3 amount not now known to him, and Claimant is informed and believes and upon such information and belief alleges that he will incur additional expenses in the future. Claimant Henry Rankin III is informed and believes and upon such information and belief alleges that he will suffer additional special damages in the future, including the inability to find employment,all these damages existing in a presently unascertained amount as such loss is not yet determined. As a further direct and proximate result of said negligence, acts, omissions and conduct of Contra Costa County and its medical care providers, Claimant Henry Rankins, III was prevented from attending his usual activities and occupation, and Claimant Henry Rankins, III is informed and believes and upon such information and belief alleges that he will be prevented from attending to his usual and anticipated activities and occupation in the future, all to his damage in an amount not now known to him. Claim of Henry R�an .ins, Jr. At all times mentioned herein, Claimant Henry Rankins, Jr. was and still is the husband of Claimant Katalin Rankins and was and still is the father of Claimant Henry Rankins, III. Claimant Henry Rankins, Jr. was present during and following the medical and surgical care and treatment of his wife and their baby and observed and witnessed, at that time,through his own sensory perceptions, the negligent conduct and omissions of Contra Costa County and its medical care providers which resulted in and were the proximate cause of the physical injuries to his wife and to his new born son. Claimant Henry Rankins,Jr. observed the delivery of his son from his wife's vagina and watched the injuries caused to his wife and son as Contra Costa County and its medical care providers removed his son's body from his wife's body. At all times herein mentioned, Claimant Henry Rankins, Jr. was a person to whom harm was reasonably foreseeable as a consequence of the existing marital relationship to his wife and parental relationship to his son. As a direct and proximate result of the aforesaid negligent conduct and omissions of Contra Costa County and its medical care providers, Claimant Henry Rankins,Jr. sustained,great emotional disturbance and shock and injury to his nervous system, all of which have caused, continue to cause, and will cause him great physical harm and mental pain and suffering, and loss to his usual occupation, all to his general and special damage. At all times mentioned herein, Claimant Henry Rankins, Jr. was and still is the husband of Claimant Katalin Rankins. As a direct and proximate result of the acts, omissions and conduct of Contra Costa County and its medical care providers, Claimant Henry Rankins,Jr. suffered the loss of support, services, love, companionship,affection, security, sexual relations and other elements of consortium, all to his general damage. 4 JESSE BANKS N&q ADDRESS 136 ODESSA AVENUE PITTSBURG, CA 94565 uv, Pipe Si., asem£^z m.asrtme'z. Phone: 925.335.1004 a r-ax: x25.335.100! CLAIM ` B ARD OF S P RV'I ORS OFCONTRA COSTA CC)LTt„! BOARD ACTION:JAN- 06, 20C Claim Against the County, or District Governed by ) 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 California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), give: Pursuant to Government Code Section 913 and 915.4. Please nate all"Warnings". t AMOL N'T: UNKNOWN CLAIMANT: .JESSE BANKS ATTORNEY: UNKNOWN DATE RECEIVED: DECEMBER 02, 2003 ADDRESS: 226 W. 12th STREET BY DELIVERY TO CLERK'.ON: DECEMBER 02, 2003 PITTSBURG, CA 94565 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN'SWEET l Dated: DECEMBER 02, 2003 By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Sup erv' ors ( This claim complies substantially with Sections 910 and.910.2. ( ) This Claim PAILS 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: f5 N s. De ut County Counsi Dated: t By: i p y 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. 40ARD ORDER: By unanimous vote of the Supervisors present: (1K This Claim is refected 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:- d JONSWEETEN, CLERK,By Deputy Clerk WARNING(Gov, code secti n 913 Subject to certain exceptions,you have only six(6)months from the date this ndtice was personally served or depositea 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:N W.0 JOIN SWEETEN,CLERK By Deputy Clerk Ctairn tei ,, BOARD OF SMFERVISORS OF CONTRA COSTA COUNTY I'*IST$UCTIC} 15 TO - { A. Claims relating to causes of action for death or for injurytci person or to personal property or gro craps and which accrue on or before December 31, 1987,must be presented not later, than the 1Ufl Clay 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 craps 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 alter the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez,CA 94553. C. If claim is against a district governed by the Board of Supervisors,rather than the County, the name of the District should be filled in. D. If the claire is against more than one public entity, separate claims must be filed against each public entity. E. 'rand. See penalty for fraudulent claims,Penal Code Sec. '72 at the end of this farm. RE: Claim By Reserved for Clerk's filing stamp Against the County oftontra Costa or } DE L' u 2003 � ' 9 District) CLERK ,ago o�stip (Fill in n'me) riacoSU Cn. Rs The undersigned claimant hereby makes claire against the County of Contra Costa or the above-named district in the sur.: of$ } and in support of this claim represents as follows: I. When did the damage or injury occur?(Give enact date and hour) Art ri.�5 C-4 4 2.` ere did the age clu t " an8 (� ctty d county) 'IL 3. How did the damage or injury occur?(Give full details,use extra p�irequft!d�11::W lig NX 1,rct wvl�� t r t. � \A_ % - 4 =., .......- .y 1 � y . ' 4. *Iiat pcular act or omission on`the part of county or district officers,servants, or employees caused the a td in'ury or damage-' 5. What are the names , urny or district officers, servants,or loyees causing theda or injury? r x Ea. What damage or injuries do you claim #ges claimed. Attach two estimates for auto damage.} 7. How was the amount clat ed computed?(Include a esti ted amount of any prospective injury or damage.) 04-- 8. Names and addresses of witnesses, doctors, and hospitals. � r"� W pq.,D „� * # A List the exp2ilitures you made o account o th> accident or injury. A } Gov. Code Sec. 910.2 provides."The claim must be } signed by the claimant or by some person on his behalf.,, SM N IQ: rn Dame and Address of Attorney } } (Claimant's Signature) r (Address) Telephone No. Telephone No. �����►«*�*.*���*:::�::*s�����,�����«�:����*::���:�::s*:sir.*���*.��#.:��#*�����:*���*:�*�����* NOTICE Section 72 of the penal Code provides: Every Person who,with intent to defraud,puts for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the satire if genuine,any Use or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonmem in the county jail for a period of not more than one year,by a floe of not exceeftg one thousand(S 1,000),or by both such imprisonment and rune,or by imprisonment in the state,prison,by a tine of not .� exceeding tea thousand dollars(S IO,000),or by both such imprisonment and fine.. .l ` l _ P t4��jy F p -I I i AON '' A5 + �i �•p-�i lam. � CT/:A,rn , � - Okit� POToa- .F cam+ .�Tr N��e�71.60 Aooreotyl rvavJ •�.��— _$ rem �S v _ -......._..._ �..�.,.__. ten....... .:.--.. .-_. '_'• j r � . Y j 9 c '1 Y .. L ti - , - - - __-- _- ---� CLAIM B0&RD F PERVISORS OF CONTRA COSTA COUNTY s ARID ACTION: JAN., 06, 200 Claim Against the County, or District Governed by ) 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 California Government Codes. notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), give: Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT- $114.42 � t CLAIMANT: ANTIOCH UNIFIED SCHOOL DISTRICT ATTORNEY: UNKNOWN DATE RECEIVED: DECEMBER 2, 2003 ADDRESS: 510 "G" STREET, BY DELIVERY TO CLEF.ON: DECEMBER 3, 2003 ANTIOCH, CA 94509 BY MAIL POSTMARKED: DECEMBER 1, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOII:INN SWEET , C Dated: DECEMBER 3 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board.of Supervisors This claim complies substantially with Sections 914 and%110.2. { ) This Claim PAILS to comply substantially with Sections 914 and 914.2, 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 claire on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.0. { ) Other: Dated: By: t - Deputy County Counst III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) { } Claire was returned as untimely with notice to claimant(Section 911.3). IVOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. { ) Other: I certify that this is a true and correct'copy of the Board's Order entered in its minutes for this date. Dated: VA I"* + JOHNN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code sec on 913) 41 Subject to certain exceptions, you have only six(o) months from the date this ndtice was personally served or depositei 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: V407r Aek , K3N SWEETEN, CLERK By Deputy Clerk Sandy Wagar ` .Permits Coordinator } Antioch Unified Schaal District 510"G'Street * Past Office Box 768 Antioch,CA 945o9 Phone:925-776-2081 Fax:925-757-6728. E-mail: sandywagarg-antioch.kl.2.ca.us F E. Oct 16 03 02: 43p Contra Costa Elections 525 646 1385 p. 2 ,OCT-14-2003 14.54 CCC RISK MANPOMENT 925 335 1421 P.02 p�3ARD OF S'i ZRVI.,t= E?F f` IM 00M COMM Claicc to: INSfRt1Ci160NNs Tro tl itlDOWN'T A. Claims relating to mouses of action for death or for itt)u2'Y person or to per- sona.l property or growing craps and Which ace�� before December o tithe cause Of must be presented Coat later than the 100th cSsY son Of action for-death or for iraurY to pw action. C},ai3rs relating to caws �� wA t�'iit�t aC cnr after .Tahuaz`y 1, or tv perscoa2 prGper'tY six months after the accrual of the cause 1988, must be presented not later than any other cause ai' action cu�st be presented not of action. Claims aft he of the rsuse of action. Wvt. Code 4911.2.) later t� OW year g. Claims c t be filed with the Clerk ole the Board af. tr et�visors ne its 9455e in CCculty �n3,nistrsttion 8uilditt8, 6�1 Fine 3tr`eet, t�rtinez CA'9�553- Room 106► C. If claim is against a district governed by the BOard of SuperVisors, rather than the Canty, ttse ram of the District sttOU be filled irt. claim is against more than one public entity, separate claims must be D. If the filed apimt each trsblic entity. "Penal.Code Sec72 at the end of this R. Fraud. See penalty for fraudulent Claims, . * � earrr rrr ctrrrar * era ) aReservedfor*Clerk's filing Stamp ) RE: Claim BY Antioch Un CEDE FD Antioch, CA 9 tra C'to 0 R 2003 ' the C,cxs tY or OIL E Y B0AR 0 0F -ztj°Pf RV . District) QQN RA 1Q4 TA fQ ,_ its rime ) Ma Tttetdersigrted C�.silt '� kes against the CA►�nty of C.cmtra Cos ofor the above-cmed District in the mn ref $ �i114 tib and in support this claim represents as fOUOWS z e ar in�urY Ocour? (Give exact date and hour) 2. When did the dt„ma,� ._ .. _ . October=-7-,- 2003-= -Sped l-ETection at 9:455 a.m in ...�. ...� _ .V_ or in3ury occsu'? {Include city and cotmty) 2. here did the Contra Costa County - 4325 S au - Antioch, CA_245Dq_.._ Mno Grant oecun'? (C3ive full details; use extra paper if 3. door did the damage or inu:`y required) One of the pollworkers or inspectors spilled coffee on several library books. at icu'tar act or cmiss,= art the Hart of �tY or district officers, 4. s tervartts or.emplOyees caused.the-in.jurY or e? PollworkersjInspectors are told in advance when using any school libraries they are not to bring in food or drink. This request was ignored'. The hot coffee ruined the books to the point of no repair. ,.Oct 16 03 02:43p Contra Costa Elections 925 646 1385 p. 3 OCT-14-2003 14:54 54 CCC RISK ht"GMENT 925 335 2421 P.W �. Wnat are trte names of CoMty or district officer3+ servaxlts tr empioyees causing the doge or injurY' Peggy Fagen, Gladys Gipner, Damon Fagen Dorothy White and Eugene Daly . Injuries do you resulted? (Give full extent of injuries or t damages claimed. Attach two estimates for auto daw4to See attached list of books and their cost. Spilled coffee by your workers damaged _ --- ---- d? (dude the estamatad amount of any 7. Hou was the amount c:.aimed above cx prospective in,jurY or damaP.) Librarian checked her records with purchasing to determine exact cost charged the school for the books. ..... g. Names and addresses of witnesses, doctors and hosAi tals Marilyn Warren - Library Technician - Mno Grant Elementary School 4325 Spaulding St. , Antioch, CA 94531 e ora actin t of this accident or i jury: 9. List the expend itures you mad _ DA.TF. rTEM October 7, 2003 School Books $114.42 11 e +� 0 � * � e +r .0 1� a s e * e a � -s �►.+� a a s 1tes.• Q�2e �vi.des: � :• a e +t,w Geri. Code Sec. a.1 � by Wt� claimant or cle.'im must be signed 3� 14QTI. TC1s (Attr�r�c � orrson on his.bdmlf- Name and gddr= of Ott y AVSD - Sandy Wagar - Fept. airnanL .5 No Attorney involved. 510 "G" S � Access - Antioch, CA 94.509 - Telephone NO. 925-776-2081 * e e Telephone 0000000 HATICE Section 72 of the Penal. Code provides: ce or for " on who, with irr'+.ent to defraud, present3 for allo4an ' car to any etc mty, city, or district board or � t to any state board ar Officers rte, eny �, or fraud�il.ent off'ioer, authorized to allow or 1 Y the same if moble either by 1Mpr13OT nt in claim, bill, sit: voucher, or writing, en yea • by a fine of not eacoseding the county Jail-fnr a period of t 01=40 them J pr'isor�raent in one thousand 01,000), br by both such iqr-isalment �1 fidol or' by a fine-Of hat etCeedin8 t,eu thcusuct.dollar's (�i1.Q: + �"' by the state prim,, � and f irle. both such impri=mnt TOTAL 4'.03 10/15/2003 15:43 7566068 GRANT ELEMENTARY PAGE 02 Mno Grant Library 4:325 SPAULDING Srr3EsT ANTIOCH. CA 94531 925-706-5271 DAMAGED BOOKS FROM OCT 7TH ELECTION Title Author publisher Cost Amelia Bedell& Peggy Parish N.Y.Harper Collins $%00 00 Good Hunting, Entre Sky Peggy Parish N. Y. Harper Collins 8.75 Amelia Sedalia and the Surprise Shower Peter Parish N.Y,Harper&Row 14A9 Thank you,Amey Bedella Peggy Parish N,Y.Harper&tow 8.75 Play Basil, Amelia<Bedew Peggy Parish N. Y.Her&Row R75 Come lack,Amelia Badells Peery Parrish N, Y,Hater&Row 9.87 Amelia Badella's Family Album Pew+Parish N.Y.Greenwillow 11.95 Marry C hrtatmass,Amelias Sedeilat Peggy Parish N.Y.Greenwillow 9.96 The Spooky Hallowsm Party Annabelle Prager N.Y. Ranclom'House 8.99 Genghis#Chan-A dog Star is Bom Marjorie Weinman Sharma# New York random Nouse 9.96 Henry and Mudge and the Hay Cal Cynthia Rylant N.Y.Bradbury Pry 12.75 11 Bake Total Thank you, Mati"Warren,Library Technician 10/15/2003 15:43 7566068 GRANT ELEMENTARY PAGE 01 �rf Oct 16 03 02; 43p Contra Costa Elections 925 646 1385 P. 1 STEPHEN L.WEIR CANDY LOPEZ COUNTY CLERK 'f ASSISTANT REGISTRAR CONTRA COSTA COUNTY REGISTRATION-ELECTION DEPARTMENT 524 MAIN STREET MARTINEZ,CALIFORNIA 94553-11401 (925)648-4166 FAX#; (925)6461385 DATE: - TO: FAX#: i '7 FROM: PHONE: _ �'o TOTAL NUMBER OF PAGES TRANSMITTED INCLUDING COVER PAGE: IF YOU DO NOT RECEIVE ALL OF THE PAGES, PLEASE CALL (925) 646.4156 BETWEEN THE HOURS OF 8.00 AM AND 5:00 PM. 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CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: JAN 06,, 200 Claim Against the County, or District Governed by } 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 California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), givf Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $200,000. CLAIMANT: MARGARITA TORRES, ALLIIN TORRES ATTORNEY: UNKNOWN DATE RECEIVED: DEC. 03, 2003 ADDRESS: 36 FIRST STREET, BY DELIVERY TO CLERK ON: DEC. 03, 2003 RICHMOND, CA 94501 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, JOHN SWEET , 1 Dated: DECEMBER 03, 2003 By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Superv' ors This claim complies substantially with Sections 910 and.S110.2. ( ) 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). O Other: Dated: ( N , , t Y, By. .�.- � T, Deputy County Counsc 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). I ARD ORDER: By unanimous vote of the Supervisors present: (4" This Claim is rejected in full, O Other: I certify that this is a true and correct*copy of the Board's Order entered in its minutes for this date. Dated: . ' JOHN SWEETEN, CLERIC, By , .Deputy Clerk WARNING(Gov. code sec ' n 913 Subject to certain exceptions,you have only six(6)months from the date this ndtice was personally served or depositec in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter, If you want to consult an attorney, you should do so immediately, *For Additional Warning See_ Reverse Side of This Notice, AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California.,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above:. Dated: .c « JOHN SWEETEN, CLERIC By Deputy Cleric NOU-19-2003 13:03 CCC RISK MANAGMEN7 925 335 1421 p,01 Claim to: BOARD OF SWERYISORS OF CERA CESTA COUt immmoNs To a A1IAW A. Claims relating to causes of actions for death or for injury to person or to per- sona:l property or growing crops and which accrue on or before December 31, 1987, must be pre med not later than the 100th day after the accrual or the cause of action. Claim relating to carries of acti+od for death or for injury to person or to personal property or growing crops andwhich hich acs on or after January 1, .1988, roust be presented not later than six mouths after the accrual of the cause of action. Clams relating to any rather cause of action must be presented not later t."An one year after the accrual of the cause of action. (Govt. Code §911.2.) S. Claims must be filed with the Clerk of the Hoard of Supervisors At its office in Roam 1.461 County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district. governed by the Board of Supervisors, rather than the COunty,* the name of the District should be filled Sza. D. If the claim is against, more than one public entity, separate claims 'must be filled against each public entity. E. ' Fraud. See penalty for :rmudulent claims, Penal Code See. 72 at the end of this fearaait. e �taaaar► apt * ar� �taa �trta � aeeaae � �ta � a * aaa * � � RE: Claim By 7 Reserved for Clerk's filing stamp RECEIVED or xra ta DEC 0 3Q03 t 3C ## District) BOARD OF SUPERVISORS . � The undersigned ciat hereby-makes claim.a� ainst the County of Contra Costa, or the abc�re�-named District in the sum of u t 0 00 _ and in support of this claim represents-as fol3.ms f Z. When oliol the damag,%.or in .. � occur? {Give exact date and hour) 2. Where did the dame or injury c url' (Include city and co wty) 3. How did the damage or injury occur? Give full; detailsl use extra paper ,._ required) , vniLft W 4. What particular scat or cmi�,or3 an u4 ps�t of awxaty or district officers, �. 3erv=tas car.ems caused.the.injury or. ? NOV-19°2003 13 x 04 CCC RISK IANAGMENT 925 335 1421 P.02 D. what are the res of county or district office, serMtS Or e.Mp10y :s Causing the dame or injury? 6. 'What damp or injuries do you claimresulted? (Give full exert of injuries or damages claimed. AttAch two estimates for auto damage. 7. How was the amount cUlmed above Computed? (Include the estimated amount of any prospective injury or e. 3« Names and addresses Of'.witnesses, doctors and hospitals. ^ V y-, 10,-e,olt arc , evik &Uns= q« List the expenditures you made on account of this accident or in jury: DATE T',tEH AMOMT • ee * � eeeaEe .eeeeeee �te-� �t.�taaesee•eaeeea � �teee_ � �eak GoV. Code Seo. '910,2 grovides: "The claim mast be signed by the claimant SM NOTICES TOO CAttorne or sme cin his.kkw." >en Address or Attorney a �gr�a�ure (Addre ss Telephone Not. Teelephone� No. 0 737 ci"4-C- + s e aE ae a e e �t ak `e aW it I a W.W". "'. "e.`a'" NOTICE Sectica 72 of the penal Code providest "Every Persm who, with Intent to defraud, presents for all owncee 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 am if.g+enuines any false or fraudulent claim, bill, account, vcueher, or writing, is punishable either by imprisoliment, in the city jail.•fors a peri*d of not mmv than coo-year, by a fine of not exceeding One thousand (*1#000)1, or by 'both such i!#risearnent and finei-or by imprisonment in the state Priam# by at fine of not exc eedirsg ten thousand dollars (410,000, or by both such impriwzment and fine. TOTAL P.02 STOPIO The following pages are medical records. Do not print or distribute without written consent from County Counsel. CONTRA COSTA COUNTY CONTRA COSTA HEALTH SERVICES To: Anna Threadgili date: November Cil, 2003 36 1 st Street Re: Torres,Alvin Richmond, CA 94801 MR#: 86 - 22 -20 - 1 REPLY TO MEDICAL To Whom It May Concern: RECORDS AT: Receipt of a request for medical information on the above-referenced patient is acknowledged. Contra Costa Regional Any items checked below are applicable to this request: Medical Center Contra Costa Health � All the information requested is enclosed. Centers This information is STRICTLY CONFIDENTIAL and is for the information only of the 2500 Alhambra Ave. person to whom it is addressed. It Is unlawful to give this information to any Martinez, CA 94553 other party. 925/370-5220 Enclosed is all the medical information which by law is permitted to be disclosed. This information is STRICTLY CONFIDENTIAL and is for the information only of the person to whom it is addressed. It is unlawful to give this information to any other party. 71 Medical information may NOT be released without written consent of the patient or guardian. Upon receipt of an authorization, following the guidelines set forth in Part 2.6 (commencing with Section 56)of Division 1 of the Civil Code, and signed and dated subsequent to the treatment period covered,we shall act on your request, For your convenience, an authorization form meeting those requirements is enclosed. We are unable to identify this individual. Please provide additional information; e.g., date of birth, social security number,treatment date, verification of spelling of name or other names patient may have used. The authorization we received does not comply with the requirements set forth by the Confidentiality of Medical Information Act, Section 56 of the Civil Code and/or Evidence Code 1158. Please have the patient/guardian complete the attached ai Ohnri7afinn The information you have requested was previously mailed on: ElYou will be billed for this service under a separate cover. ElBilling records for patient's care will be sent under separate cover by our Business Office. El Other: Very truly yours, A - Original: Correspondent ' Copy: Chart � i ' AAA=== CONTRA COSTA HEALTH SERVICES PATIENT REGISTRATION MEDICAL CLINIC P/T O Financial Class Code NO NO tv1 hserv. M101-85-0005 Work Related? N Dr's 1 stPa c Tye Voluntary Clerk/Cin Medicare? N St.Facts? (3�"K03213 swigram Insurance? N N Plan? NPST �S NAME ALt�ZN J Medi-Cal? N Vet? S/D? M/Y/$ Previous Change V91TE HISP Coverage#1 INTERDEPT MISC p Policy# IDNO Wx � -P-13/1985 A Information Coverage#2 Ira-AS-0000 I.D. NG D. Stat Policy# �� � S Information Maiden Name Mother's Maiden Name Coverage#3 Policy# How Arrived Information � SH" Other Insurance Address/Phone Note: ATTN ISAEEL ONGKINGCO #k MARTINEZ CA 94553f3tsGIERr MARTINEZ CA 94553 Pt. Employer Dan 4f Night Phone 1 -4775 Occupation Local Address Employer's Address PARTY HALL Res .Party s Em o erir} D.O.B. tion Sex No IN W'oi F FCE ' — t TH Resp.Party's Employer's Address Soc.Sec.# I.D. 090"00 Subscriber TORRES ALV I N 1PH dit qI ER DR, ; Soc.Sec.# Employer MARTINEZ CA 94553 0"00�t30"if1GC33 1>ay Phone Night Phone EMEROENCYNTACT "IMSIE 'C�RK PAM, RF-FROff MART &CLINIC Relationship qR' " .GRAND A�; Da Phone Night,Phone A # # T' a Pre-Admit E.D.A. '01235-866 ` ' '' 'a ' ; 314 Address 62 — CLINIC REF 1 — ADV DIR NOT AP NEXT OF KIN Relationship Room Bed Mod Sery Are. Od. Pay Phone Night Phone Smoke Religion Inquiry Address Last Admit Date Place NOTES Patient Unable to Sign Consent to Service M0703 El Consent to Service on file Consent to Service Signed dated (Signature of Registration Clerkj ADMT-01 (12197) C,y,ciRT M.D. Discharge Date: Time: CONTRA COSTA COUNTY HEALTH SERVICES D E T E N T I O N F A C I L I T Y 0 MDF E West Co. C] Marsh Creek EMERGENCY ROOM CONSULTATION lam-✓ . CHIAT ALLERGIES: Z,�LL 6 MODULE: PERTINENT PAST HISTORY: CURRENT MEDICATIONS (Name & Dose)--t9- S. PATIENT COMPLAINT: - `r O. OBSERVATIONS/FINDINGS: BP: P: R:,,JI T: ri • r A. NURSING ASSESSMENT: -- P. PLAN: _ PHONE CONSULTATION ONLY VERBAL ORDERS: MOVE TO M MODULE - SEND TO ER FOR:.ge� 4 ' .., _t77 AM ° DATE �y ' �v3 TIME: 3-2j45-QrMSIGNATURE/TIT - � DISPOSITION: ADMITTED TO HOSPITAL RETURNED TO JAIL MDF REVIEW BY: Date Original - CHART MR-468 02/92? Pink - ER Yellow - DF/QA ACKNOWLEDGMENT I have received a received: copy of the Contra Costa County Notice 1. Admance Directive Aud t PalY phiet of Privacy Practices. 2 Patient and Privacy Notice Signature �•f '' SERVICES -. Hospital 91i Dil tt� oti ATIENT REGISTRATION Date Signature EMERGENCY DEPARTMENT Financial Class Code NO NO Med.Serv. Patient# E/R 8 522.201-02-100-01 Work delated? N Dr's 1 at Patcom Type Voluntary Clerk/Con Medicare? N St Facts? t3 fi$6 31821 E kwat s on Insurance? N H Plan? N PATIENT'S NAME Medi-Cal? Vet? TORRES S!D? M/Y/$ Previous Change Race Coverage#1 INT.-ERDEPT MI`S�,, X RITE HIS! Policy# Sex D.O.B, Age Information IDNO M 11/la,/1,989 0,13 Coverage#2 �' - , Soc.Sec.# I.D. M.Status Policy# S INC Information Maiden Name Mother's Maiden Name Coverage#3 Policy# Language How Arrived Information3� L �SR Other Insurance Address/Phone Note: ATt I ARF ONGNINGCO, Patient's Mailing Address ,MARTIN ? ` 55 X02 G, FR All X T 2E Pt. Employer Day Phone Night Phone Occupation Local Address Employer's Address RESPONSIBLE PARTY -- EMe; Resp,Party's Employer D.O.B. Relation sex NOT IR:. 0 ORC :.: Resp.Party's Employer's Address Soc Sec.# I.D. OOpQt R.P.Address subscriber TC3RRE,S,:<; —AL IN Soc.Sec.# Employer RT 'Nkz,; ` . . 9 5` 0 ( =ft ! Day Phone Night Phone EMERGENCY CONTACT :. S ' 9',X , PRIMARY CARE PROVIDER&CLINIC Relationship 0 Z. N,0, IRT _ MARTI Day Phone Night Phone Admit Date Time Pre Admit E.D.A. Address 69 _ PRISON/JAI 22:40 1 ADV D I R NOT Al NEXT OF KIN Relationship Room Bed Med Sery Acc.Cd. Day Phone Night Phone smoke Religion Inquiry Address Last Admit Date Place NOTES P tient Unable to Sign on nt to service ® Consent to service on file dated (Signature of Registration Oerk) ADMT-01 (12197) CHART M.D. Dischafge Date: Time: a CONTRA COSTA REGIONAL MEDICAL CENTER 0 -104 EMERGENCY DEPARTMENT DATE '' �' TRIAGE TIME: �i _. ACE: 4'' SEX: M OF a n ARRIVAL VIA: 0 WALKING, . '*C 0 GIIERNEY D AMBULANCE ®CARRIED ❑POLICE 05150 - O TRANSFER/REFERRAC ADVICE NURSE VISITTYPE: 0 SCHEDULED RETURN ❑UNSCHEDULED RETURN c 48 HOURS �J1� yy y� «t ilyp —4A �� �� 5 k LOCATION: D LOBBY ROOM: 4 s� FIT CHART: NO YES q a s TRT1lCE STJT II III ❑IV r CHIEF COMPLAINT/HPI. rPAST MEDICAL HISTORY' 1 0 DIABETES 0 SEIZURE STHMA/COPD D CVA PAINSCAL :01234567091Jt0 �CARDIAC(LIST): j INTERPRETER: SIGNATURE: OTHER: INTERVENTIONS: 0 WA Q MASK d ICE D DSG 0 NPO OTHER: 0 D LABS: ❑X-RAY: ❑MEDS: MEDICATIONS: HOPE ALLERGIES: ©NKA DOMESTIC VIOLENCE:DYES 10 0 A e`per LMP: G:-P: CONTRAC LASYI-ETAN IME lNf IALS 6 P 0}y R T ❑R TY�E BP P O,SAT WGT: KG VACCINATIONS: ❑CURRENT f J.�+. 4f 0 I ROOM: INITIAL PHYSICIAN'SORDERS/TIME MD ORDERED: i NOTED LAS: ❑CBCD 0 ER BASIC❑COMPER ❑CRP 0 ESR D PTtptr F,TYPE&SCREENICROSS X ME BEEN BY MD: O CARP D LFP D LIPASE 0 GLUR 0 BCX ❑ER PREG ❑UA/A&S Q PREGU D UTA TOX i OABGs OTHER LAB: TIME NURSE XRAY: 0 PCXR Cl CXR OTHER: CLINICAL S&S: I o.,-> EKG: Q CLINICAL S&S HISTORY&PHYSICAL EXAMINATION TIME ORD. 1 PHYSICIAN'S OVIDERS NOTED D MONITOR SPO, r`CHEM BG C]O,: [I Td BOOSTER ['IV: r y r STAFF NOTE: 0 CONSULT/MD: DISCHARGE DX: 61t w NURSES NOTES REVIEWED D SEE ADDITIONAL NOTES N;TiFfCATION- p CORONER M POLICE 0 CPS Q ORGAN DONATION DIC CONDITION: PROVED 0 ALERT&AMB 0 CRITICAL EXPIRED a OTHER: 0 DISPOSITION: METODY 0 PES ❑ADMIT D NO DICTATION SIGNATURE t. 0 LWBS D AMA [7 OTHER: CTAT[ON C.� MCI J MR 889.8(5103) CHART EMERGENCY DEPARJrMENT ROW CONTRA COSTA REGIONAL MEDICAL CENTER E.D. NURSING RECORD NEUROLOGIC PSYCHOLOGICAL CARDIOVASCULAR RESPIRATORY ABDOMEN/GU MUSCULOSKELETAL ®NIA TO CIC [ N/A TO CIC ❑NIA TO C/C ❑N/A TO CIC []NIA TO C/C O N/A TO C/C M TAL STATUS BEHAVIOR S SIGNS LUNG SOUNDS O Ambulatory ully Awake Appropriate ormai Color Dry O Clear B.S.Present C]Abnormal Gait riented ami Warm []Hot Cool []Wheezing -„�L_R B.S.Absent ❑C spine precautions O rousable to fg,,, estless []Anxious Cyanotic O Pale —i_E O No O Swelling C]Deformity Communication or Stim. 0 Crying;Inapprop. ❑clammyG Flushed r-Rales _L,_,R O Non-tender ®Discoloration No Response to Stim. -1 [ Rigid ❑Redness O sp [�Uncontrolled [)Diaphoretic O Rhonchi _L�R ©Tender ®Abrasion S ECH ©Agitated O Jaundiced I Decreased—L,_R ❑Distended O Lacerafi n Coherent O Combative RkILSES ®Caugh�P—NP O Emesis O Rash Burn Ir ®Paranoid Strong O JVD PATTERN {�Diarrhea Neuro- ascui r Check Slurred C Hallucinating O rl g O p Vag Bleed a l [7 Haemal [] egular Pedal Regular Labored []Delusional GRIP STRENGTH Irregular [❑Edema ®Accessory Muscles ❑Vag DIC Loca ion Non-Verba! p Nasal flaring quaff O Threatening CAP REFILL O unequal -"N/A Pressured Speech O Normal d Abnormal Cry: ®Strong ❑Weak PQ 1. PILS RLA r'1 N/A DESCRIBE ABNORMALITIES: � - GLAS4;0,0 R NJA Scale O Tremors �+Ai�t 3 is ;c 1.9. 4 6 6 1 8 9 164, 6 '•�` VISUAL ACUITY L I R 12 CORRECTED1 SIGNATURE: , ILNFN TIME TYPE B I P P R T Cather PAIN TIME REASSES MENTIEV I ILLATIONS INITIALDo 7 10 iallqd )60 10 Pi At 0,S64 qQE 10 per--- `� 10 10 Q_Q I 10 /10 /,0 TIME INTERVENTIONS INIT. BELONG NGS: nME ❑ TO UNIT ❑ SEE ADDITIONAL NOTES MEDICATIONS SITg,- TIME ❑ 02 LITERS: VIA: MED I SOLUTION DOSAGE --ROUTE IN1T. ❑ EKG ❑ STAT¢10" ❑ ROUTINE0 . C484-4,,a lei 7r ❑ NEBULIZER TX ❑RT ta ❑ CARDIAC MONITOR Pu RHYTHM X-RAY: TYP : ❑ PCXRRETU ❑ IV#1 SITE: ❑ SL TYPE: O PARAMEDIC START ❑ IV#2: SITE: © SL TYPE: O PARAMEDIC START ❑ BLOOD SPECIMEN DRAWN L R T B BC SITE: 0 LAST 0 FIELD DRAW Ll URINE SENT C.]CC: O CATH O BAC INTAKE OUTPUT ❑ FOLEY Ir: PO IV URINE ":. EMES13/NQT OTHER ❑ NG TUBE fr: ❑ LAVAGE " IRRIGATION ALac O Wound O Eye O Ear x ❑ GEN PROBE SENT O E e O Gu 111 0 C 0/ ❑ DIP-UA PH SCG , I t O LEUKS®_ZI NIT O URO O PRi? O GLU____Q BLD KET BIU ADDITIONAL SIGNATURES 1NIT. i; C V-q t '� 111 IAly a MR387-2 (6/01'1 ruhtrr — WOIRIt/SCHOOL RELEASE ► PATIENT NAME ADDRESS w-p AUTHORIZED FRC,ft x:07 X W 1IIf&K;� - :7t �{INSTRUCTIONS IN SPANISH €� []SCHOOL � " INJURY °. W :. DUE TO— , C I} D€s .ILLNESS I ft Sig: F� 3 VOID: COPY ONLY FROM, RETURN DATE: cy � zz;�2 a Sig: D€sp:ul ' RESTRICTIONS: � m 5+4 :=> VOID: COPY ONLY r E9r . 95 i oQ : w0 FROM:- .. h. Dis w TO: iOI COPY ONLY SIGNATURE ' n SIOt P URE'. ®TRANSMITTAL OR DATE: V.D.!FNP i R 3 L t .. ,r OTHER IV P{ ' WORT ING DIAGNOSIS. ✓t ��� �` ' � o,t�L' j w1> a_..� r �� ❑00 NOT DRIVE HOME FROM THIS VISIT. / INSTRUCTIONS ON REVERSE OF PAPER. 0 PRINTED INSTRUCTIONS GIVEN: ; C❑WOUND CARE El SPRAIN/FRACTL3RE VOMITING/DIARRHEA UTI C ASTHMA!COPD [I X-RAY. �SCREENING NURSE HEAD INJURY CASTS/SPLINTS LJ COLDS/FLU EARLY PREGNANCY ❑EAR INFECTION READINGS DRIVING CAUTION 0 EYE INJURY ❑`BACK/NECK INJURY Il FEVER CONTROL ❑VAGINAL BLEEDING CI ABDOMINAL PAIN Q LABORATORY Q REGULAR PROVIDER tfTE OTHER INSTRUCTIONS --2 y.q /. t_l_.-j 14`yi..�. �'�"c G'#F..'=�"^,-.- ^r�:'S-* �f,...x+"' S7r-1,.1t+:^.-. �'�,.i...�2 J ,-i;.Z.•i,r(/ � 4's �.:'�-s?' t : �.f.✓s.i x+31�L1. .'(r� { w��_ �.,�+,- r :..-•*� J�`fiR "�✓'9 �L(,J t-g �.. •• �q,..,_. � �- � �. .��'� ��" �'Gr€..�'%. �'�+.,:'T :.z+" "' w io t � �°+.--.�G- `�S- Ye..-7 1 G 7�.-._:v t. •�,�"-• 1. I,,.-r�.:. !"n. (a..th-•1..,, FOLLOW-IJP APPOINTMENT: El CONTACT APPOINTMENTS FOR FAMILY PRACTICE APPOINTMENT IN DAYS/WEEKS ZRETURNTO EMERGENCY DEPARTMENT IN 'r DAYS 4 0 AOOINTMENT SLIP GIVEN. SPECIALTY A PO TMENTS: El MESSAGE LEFT AT AAPOINTM T UNIVYOU� , IC_L BE CON;TACTEQ A YOUR APPOINTM T, T W(RKk .DAY .if:Y�/U HA ,` ='CLINIC' l fes. DAYS't WE KS -'NOT' EN,CCJNTACTEI�AL � INTN UN�T AT 800-496-8885. APPOINTMENT SCHEDULED O'N-OSOTAOS HEMCSO DuADO UN MENSAlE C-N.LA UNiDAD DE CITAS. CLINIC/PROVIDER ` w SITE". -DATE UD.SERA CONTACTADO DENTRO DE 2 DIAS HABILES.Si NO HA SIDO CONTACTADO,LLAME AL 800-495-8885: CLfNIC7 PROiOE SITE DATE TIME STAFF INITIAL - SIGNAT;URE YOU NEED TO PICK UP UNDERSTAND ESE INSTRUCTIONS(Patient Signature) '` REMAINDER OF lFtVP PRESCRIPTION TIME DISCHARGEDI HOW DISCHARGED INTERPRETER ALKING C,W/C 0 CARRIED ❑GURNEY*OTHER: 00 ADDmoNAL NURSING NOTES/DISCHARGE: T i GUARDIAN VERBALIZES UNDERSTA14DING OF INSTRUCTIONS !GUARDIAN GIVEN ER PRINTED)DISCHARGE!FIX:INSTRUCTIONS olf DISCHARGE PLATINING 1 ASSESS. NO NEEDS SOCIAL SERVICE REFERRAL: 13YES ®NO UTILIZATION REVIEW REFERRAL: OYES ONO HOME HEALTH REFERRAL 0YES ONO` DURABLE MEDICAL SOUIPMENT REFERRAL OYES ONO EQUIPMENT: LIVING ARRANGEMENT: LIVES ALONE®YES ©NO WHOM SUPPORT SYSTEMS: DYES ONO WHOM: ADDITIONAL DISCHARGE PLANNING: DISCHARGE PT EDUCATION.- GIVEN'RX TO BE FILLED C STARTER DOS€ ©HEALTH CARE SYSTEM NUR G TUR€ � GI DSG APPLICATION AND CAR 0 WOUND CARE 0 DIET 0 SELF-EXERCISES €:;RESP.DEVICES D ASSISTIVE DEVICES: 0 CRUTCHES 0 ORTHOPEDIC DEVICES CONTRA COSTA HEALTH SERVICES MR#: 00-86-22-20-1 CCRMC, Martinez Health Centers NANIE: TORRES, ALVIN J. 2500 Alhambra Avenue, Martinez, CA 94553 DOB: 11/13/1989 EMERGENCY DEPARTMENT REPORT DATE: 7/4/2003 CHIEF COMPLAINT: Got in a fight, pain and swelling of the left foot and laceration to the chin. HPI: The patient is a 13-year-old male brought in from juvenile hall,who states that he was in a fight with a bigger guy, who threw him down on the floor. He hit his left foot first and then down on his head. He did not pass out. He denies any vision changes. No nausea or vomiting. He is only complaining of the laceration pain and left foot pain. He has no paresthesias. PAST MEDICAL.HISTORY: Mild asthma. MEDICATIONS: Include albuterol. ALLERGIES: Pepper spray. EXAM: VITAL SIGNS: Blood pressure 135/94, pulse 102, respiratory rate 20, temperature 99.2. GENERAL: The patient is nontoxic-appearing. HEENT: On his face, he has equal pupils and full extraocular movements. He has mild erythema diffusely over the whole mandible and diffuse tenderness over the left angle of the mandible and mild tenderness at the right TMJ all the way down to the angle. He has no trismus or malocclusion. His teeth are not loose. On his chin,he has a 2-cm laceration, 4 mm deep. I am not able to see the bone. Bleeding is well controlled. NECK.: Supple. LUNGS: Clear bilaterally. HEART: Regular rate and rhythm. CHEST: The chest wall is nontender. ABDOMEN: Thin, soft, and nontender. EXTREMITIES: On his right lower extremity,he has moderate swelling of the dorsum of his foot. He is able to move all his digits, and he has intact sensation distally. He has no bony tenderness or swelling at the malleoli. EMERGENCY DEPARTMENT COURSE: The patient was given ibuprofen and Tylenol. Orthopantogram was ordered, but, unfortunately, the machine was not available, so a limited facial series was done. There was no obvious fracture of his mandible. His right font, however, shows a distal 2nd metatarsal fracture, a mid 3rd metatarsal fracture, and a fracture of the base of the 4th metatarsal. No evidence of fracture of the 5th metatarsal. The patient had a posterior splint placed with 90 degrees at the ankle with minimal problems. His wound was anesthetized with 0.25%bupivacaine with epinephrine. It was irrigated with a copious amount of fluids and was brought together with 6-0 nylon. The patient tolerated the procedure well. ASSESSMENT: 1. Right 2nd, 3rd, and 4th metatarsal fractures. 2. Facial trauma with chin laceration, no obvious mandibular fracture. D18P0SfJ'f0N: To juvenile hall. PLAN: Tylenol#3 with codeine with ibuprofen every 6 hours as needed. Elevation of the foot. Followup with orthopedics in 2--3 days. No weight-bearing on the right foot. He was instructed to have the sutures out in 5 days. The patient understands, as does his caretaker. ORIGINAL Page 1 of 2 EMERGENCY DEPARTMENT REPORT MR.#: 00-86-22-20-1 NAME: TORRES, ALVIN J. Este a Hernan z. MD EH:tjm d: 07/05/2003 02:35 AM T: 07/05/2003 11:18 AM Job: 15196811' ORIGINAL Page 2 of 2 EMERGENCY DEPARTMENT REPORT 7 04 3 GPD CONTRA COSTA HEALTH SERVICES CONTRA COSTA HEALTH CENTERS AMBULATORY CARE TRRES ALYIN� � � � CONSULTATION FOLLOW-UP NOTE: This form is to be used for consultation follow-up ftA.R r (off-site and same-site)and for patient initiated Specialty Care ss; CONSULTANT'S REPORT Date of Visit: [El Self Referral] Clinic Type: Send Report to: Cl AHC/AMC 7 BHC 13 BPFHC 0 CHC/AMC EIECAMC CIMTZ ❑LARCH O PHC O RHC rte'`C Chief Complaint: - ' Allergies: r Pain: ® No CAI. n FINDINGS - L v � Nurse Signature [❑ Dictated Of so, please write diagnosis and plan below.)] r Lo urTV6 --r r 1 is a 4 C Chart Check to PCP? Cl Yes 0 No Original:Consult site Consultant (please pint and sign) Dace Yellow: Requesting Site MR191A-0 (4-01) Pink: PCP AMBULATORY CARE CONSULTATION FOLLOW-UP CONTRA COSTA HEALTH SERVICES CONTRA COSTA HEALTH CENTERS AMBULATORY CARE CONSULTATION REQUEST } NOTE: This form is to be used for consultation requests (off-site and same-site). TO: X MTZ ❑ RHC ❑ PHC cans i t{o Appointment Date ❑ Outside Provider FROM: ❑ MTZ ❑ RHC ❑ PHC ❑ CHC/AMC ❑ BHC 11 AHC/AMC - '+ ❑ BPFHC ❑ NRCH ❑ ECAMC ❑ Homeless ❑ Planned Parent. Other � ° SPECIALTY: _ r&t1 REFERRAL PRIORITY: ❑ !� 10 daysO ❑ -9 6 weeks@ ❑ Routine (specialty check-ups)4) ❑ Non-urgent(expires after S weeks if not made)* CONSULTATION REQUEST: ❑ Evaluate and advise. I will follow this patient. ❑ Please assume care for this problem. IF SURGERY INDICATED: ❑ Schedule and notify PCP. ❑Consultation only. Discuss with PCP before scheduling. MEDICAL INFORMATION TO BE SENT: ❑ Nene ❑ Labs ❑ X-rays, PURPO E OF CONSULTATION: get 4: ORT-HOPEDICS AUG 0 5 2nn3 initials: P!"' Date: '7— ':2y-6U Beeper# yM# Referring Provider's Name (please print) CONSULTANT'S REPORT [❑ Dictated—If so,please write diagnosis and plan below.] C)z BROKEN APPOINTMENT ❑ PRN Consultant (please print and sign) Date ❑ Send Reappt. Notice Mnra PAW-dwg r Reviewed by Primary Caro Provider/Referring Provider Date Conn* corm"MR18i-6 (4-41) cGWdenra na kiH dks1Recwd Y911w.Vt aa�osfte PinicPCP AMBULATORY CARE CONSULTATION REQUEST CONTRA COSTA HEALTH SERVICES 0 05 0 y CONTRA COSTA HEALTH CENTERS AMBULATORY CARE 31R : CONSULTATION FOLLOW-UP NOTE: 'Phis farm is to be used for consultation follow-up 8 2220— (off-site and same-situ and for patient initiated Specialty Care. J N"T N:s o U • so PN CONSULTANTS REPORT Date of Visit: [❑ Self Referral] PIricType: _~~ Send Report to: ❑AHCIAMC ❑BHC ❑BPFHC C❑CHCIAMG* ❑ECAMC ❑MTZ ❑NRCH ❑PHC ❑RHC ❑ Chief Complaint: Allergies: Pain: ❑ No ❑ Yes: Intensity: FINDINGS Nurse Signature [❑ Dictated (If so, pl a e write diagnosis and plan below.)] ORTHOPEDi, ., 74 Ith Chart Check to PCPP ❑ Yes ❑ No Original:Consult Site Consultant (please print and sign) Date Yellow: Requesting Site MR191A-0 (4-01) Pink: PCIS AMBULATORY CARE CONSULTATION FOLLOW-UP CR COSTA IEAI_rll SERVICES -- 1 CONTRA cosrA HEALTH CENTERS AMBULATORY CARE CONSULTATION REQUEST NOTE: This form is to be used for consultation requests (off-site and same-site). %TO: MTZ ❑ RHC ❑ PHC Outsi CONTRA COSTA HEALTH SERVICES MR#: M008622201 CONTRA COSTA REGIONAL MEDICAL CENTER Name: TORR.ES,ALVIN J CONTRA COSTA HEALTH CENTERS Ph #: (925) 646-4800 DOB: 11/13/89 Sex M DXAGNOSTIC IMAGING D3PARTMEN'T Loc: 3-B Acct# : M074631821 REPORT PCP: PCS: MART Ordering MD: Buoncristiani,Amy C. Order Date: 07/04/03 Order Time: 2254 SERVICE DATE: 07/04/03 SERVICE TIME: 2320 RIGHT FOOTr 3 VXZWs CLINICAL INFORMATION: Pain. Fractures to the second through fifth metatarsals are noted. Only the first metatarsal appears intact. Displacement with slight angulation is most noticeable where the second and third metatarsal fractures are located. The fourth and fifth metatarsal fractures are essentially undisplaced. No dislocations of the joint space are visible. CONCLUSION: Multiple metatarsal fractures, see above. PETER W. WON, M.D. h. ut IN, WONP : RRO Dictated : 07/05/03 Transcribed : 07/09/03 2255 DIAGNOSTIC IMAGING REPORT Page 1 of 1 982(a)(17)(A) INFORMATION SHEET ON WAIVER OF COURT FEES AND COSTS (California Rules of Court,rule 985) If you have been sued or if you wish to sue someone, and if you cannot afford to pay court fees and costs,you may not have to pay them if: 1. You are receiving financial assistance under one or more of the following programs: • SSI and SSP(Supplemental Security Income and State Supplemental Payments Programs) • CaIWORKs(California Work Opportunity and Responsibility to Kids Act,implementing TANF,Temporary Assistance for Needy Families,formerly AFDC,Aid to Families with Dependent Children Program) • The Food Stamp Program • County Relief,General Relief(G.R.),or General Assistance(G.A.) If you are claiming eligibility for a waiver of court fees and costs because you receive financial assistance under one or more of these programs,and you did not provide your Medl-Cal number or your social security number and birthdate,you must produce documentation confirming benefits from a public assistance agency or one of the following documents,unless you are a defendant in an unlawful detainer action: PROGRAM VERIFICATION Medl-Cal Card or Notice of Planned Action or SSI/SSP SSI Computer-Generated Printout or Bank Statement Showing SSI deposit or "Passport to Services" Medl-Cal Card or Notice of Action or CaiWORKs/TANF Income and Eligibility Verification Form or (formerly known as AFDC) Monthly Reporting Form or Electronic Benefit Transfer Card or "Passport to Services" Notice of Action or Food Stamp Program Food Stamp ID Card or "Passport to Services" Notice of Action or General Relief/General Assistance Copy of Check Stub or County Voucher OR 2. Your total gross monthly household Income is equal to or less than the following amounts: NUMBER INFAMILY NUMBER IN FAMILY FAMILY INCOME FAMILY INCOME 1 $ 935.42 6 $ 2,570.83 2 1,262.50 7 2,897.92 3 1,589.58 8 3,225,00 4 1,916.67 Each 5 2,243.75 additional 327.08 ---OR— 3. Your income is not enough to pay for the common necessaries of life for yourself and the people you support and also pay court fees and costs. ro apply,fill out the Application for Waiver of Court Fees and Costs(Form 982(x)(17))available from the clerk's office.If you claim no income,you may be required to file a declaration under penalty of perjury. Prison and fall Inmates may be required to pay up to the full amount of the filing fee. If you have any questions and cannot afford an attorney,you may wish to consult the legal aid office, legal services office,or lawyer referral service in your county(listed in the Yellow Pages under"Attorneys"). If you are asking for review of the decision of an administrative body under Code of Civil Procedure section 1094.5(administrative mandate),you may ask for a transcript of the administrative proceedings at the expense of the administrative body. Page 7.:of 1 Form Adopted for Mandatory Use - Government Code,§68511.3; Judicial Council of California INFORMATION SHEET ON WAIVER - Cat.Rules of court,rule 985 982(s)(17)(A)[Rev.March 21,2003] OF COURT FEES AND COSTS (In Forma Pauperis) - - rNl.FORM MUST BE KEPT CONFIDENTIAL --- 982{a Cit'} ATTORNEY OR PARTY WITHOUT ATTORNEY(Nama,slats bar numbar,and addrt$4 FOR COURT USE ONLY I I TELEPHONE NO.: FAX NO.(OP60n44 E•MAJL ADORESS(OpdOnal) ATTORNEY FOR(Namak I NAME OF COURT: STREET AODRESS: ' 4 "LING ADDRESS: CITY AND ZIP CODE: SRANCH NAME: PLAINTIFF/PETITIONER: [?EI=ENCTANTf RESPONDENT: AP'PUCATION FOR CASE NUMBER: WAIVER OF COURT FEES AND COSTS I request a court order so that#do not have to pay court fees and costs. 1. a. [ I am not able to pay any of the court fees and costs. b. I am able to pay only the following court fees and costs(specify): Z My current street or mailing address is(if applicable,include city or town,apartment no.,if any, and zip code) 3. a. My occupation,employer,and employer's address arelspecify): b. My spouse's occupation,employer,and employer's address are(specify): 4. = I am receiving financial assistance under one or more of the following programs: a. ] SSI and SSP:Supplemental Security Income and State Supplemental Payments Programs b. CalWORKs California Work Opportunity and Responsibility to Kids Act,impiementingTANF,'Temporary Assistance for Needy Families(`brmerlyAFGC) c. Food Stamps:The Food Stamp Program d. ( County Relief,General Rellef(G.R.),or General Asssisstan%e(G.A.) 5. if you checked box 4,you must check and completeone of the three boxes below, unless you are a defendant In an unlawful detainer action.Do not check more than one box. a. (Optional)My Medl-Cal number is(,specify}: b. (Optional) My social security number is(specify): – = – L_77-7—F-1 and my date of birth is fspecify): [Federal law does not require that you glue your social security number.However,if you don't give your social security number,you moat check box c and attach documents to verify the benefits checked in item)$. c. I am attaching documents to verify receipt of the benefits checked in item 4,if requested by the court. [See Fw 982(a)(1 7)(A) Inforamflon Sheet on Waiver of Court Fees and Cost$available from the clerk's office,for a list of acceptable documents] (if you checked box 4 above,skip items 6 and 7,and sign at the bottom of this sidj. 6. = My total gross monthly household income is less than the amount shown on thdnformation Sheet on Waiver of Court frees and Costs available from the clerk's office. [if you checked box 6 above,skip Item 7,complete Items 8,9a,9d,9f,and 9g on the back of this form,and sign at the bohorn of this side.] 7. = My income is not enough to pay for the common necessaries of life for me and the people in my family whom I support and also pay court fees and costs.[N you check this box,you must complete the back of this form]. WARNING,You must immediately tell the court If you become able to pay court fees or costs during this action.You may be ordered to appear In court and answer questions about your ability to pity court fass or costs. I declare under penalty of perjury under the laws of the State of California that the information on bath sides of this form and all attachments are true and correct. Gate: (TYPE OR PRINT NAME) (Financial Infotmatlon on reverse) (SIGNATURE) Form AdOpWd for ManOaWy Use APPLICATION FOR WAIVER OF COURT FEES AND COSTS13—mment core. Judiatal Council of calftmia F►au rl8i (Amp §68811.3 982(a)(17)IRov.January 1,20011 (in Form8 ! 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The application was filed on(date): A previous order was issued on (date): 2. The application was filed by (name): 3. = IT IS ORDERED that the application is granted in whole in part(complete item 4 below). a. No payments. Payment of all the fees and costs listed in California Rules of Court,rule 085(i), is waived. b. The applicant shall pay all the fees and costs listed in California Rules of Court,rule 985(i),EXCEPT the following. (1) Filing papers. (6) Sheriff and marshal fees. (2) Certification and copying. (7) Reporter's fees'(valid for 60 days). (3) issuing process and certification. (8) Telephone appearance(Gov.Code,§68070.1(c)) (4) Transmittal of papers. (9) Other(specify code section): (5 Court-appointed interpreter. a Reporter's fees are per diem pursuant to Gude Civ.Proc.,§§269,274c,and Gov.Code,§§699 7,69948,and 72195. c. Method of payment.The applicant shall pay all the fees and costs when charged,EXCEPT as follows: (1)= Pay(specify): percent. (2)= Pay: $ per month or more until the balance is paid. d. The clerk of the court,county financial officer,or appropriate county officer is authorized to require the applicant to appear before and be examined by the court no sooner than four months from the date of this order,and not more than once In any four-month period. = The ap2ocant is ordered to appear in this court as follows for review of his or her financial status. Date: Time: Dept.: Div.: Room: e. = The clerk is directed to mail a copy of this order only to the applicant's attorney or to the applicant if not represented. f. All unpaid fees and costs shall be deemed to be taxable casts If the applicant Is entitled to casts and shall be a lien on any judgment recovered by the applicant and shall be paid directly to the clerk by the judgment debtor upon such recovery. 4. IT IS ORDERED that the application is denied Q in whole = in part for the following reasons(see Cal. Rules of Court, rule 985): a. Monthly household income exceeds guidelines(Gov.Code,§68511.3(a)(6)(B);form 982(a)(1 7)(A)). b. Other(Complete line 4b on page 2). c. The applicant shall pay any fees and costs due in this action within 10 days from the date of service of this order or any paper filed by the applicant with the clerk will be of no effect. d. The clerk is directed to mail a copy of this order to all parties who have appeared in this action. 5. IT IS ORDERED that a hearing be held. a. The substantial evidentlary conflict to be resolved by the hearing is (specify): b. The applicant should appear In this court at the following hearing to help resolve the conflict: Hate: Time: Dept.: Div.: Room: c. The address of the court is (specify): = Same as above d. The clerk Is directed to mail a copy of this order only to the applicant's attorney or to the applicant If not represented. NOTICE: If Item 3d or item 5b Is filled in and the applicant does not attend the hearing,the court may revoke or change the order or deny the application without consideringinformation the applicant wants the court to consider. WARNING:The applicant must Immediately tell the court if he or she becomes able to pay court fees or costs during this action.The applicant may be ordered to appear In court and answer questions about his or her ability to gLy fees or costs. Date: ( =Clerk,by Deputy JUDICIAL OFFICER Clark may GRANT in full a nondlscrationa fee waiver;sea Cal.Rules ciCnun,m/&985(4 Pegs 1 or 2 Form Adopted for MandatorgUse ORDER ON APPLICATION FOR WAIVER OF GovemmentCode,§68511.3; 9szta lis[r ev e n ary 1,22t0sl COURT FEES Ault}COSTS(in Forma Pauperis) Cal.Rtes of coxt,rule 985 (slaadned etuaod u0 S1.S0o QNV S33d.LunUo auraMnd :10 H3AIVM 80=1 NOIIV0IIddV NO H3auo l�aaa'sr�enuer n��lt��>tB)zea Aindea' Aq'�ielo :oleo aol40 Aw ui elk}uo Iaulbpo aLfl jo Adoo loeiioo pus ani;a sl f utaaiol 9411laU1 4! go I 31'd3I:111833 S,)48310 L L Alnda(]' Aq`)ijelo `upo#Ileo, :(e;eA)uo is paiin000 ollaolllliao s1q1 to uollnoaxa pus 6ulofiaiol a41 to Bu11!ew 914l llayl pua'mo leq um0t4s se passeipps adolanua poises e u1'pledeid 96alsod'sslalo;sill palllaw slam 6uroBaiol eifl;o Adoo onil la moi pus asneo slyl of Alred la lou we I leefl A}Theo I !DNI'IIVW 30 3IV31d11833 S,)1113jo :(suoseaj,#Ioeds)lied u1 io afotlm ul powep sl uolllao;Iddy = qt, :(8wt?N) LN3C]N0dS3U/INVGN3A30 aaswnrr st+� :(Gw-*N)83N011 I3dtdJliNftl"Id