HomeMy WebLinkAboutMINUTES - 12202005 - C21 CLAIM
BOARD OF SUPERVISORS OF CONTRA. COSTA COUNTY
BOARD ACTION: DEC. 202 2005
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), gives
Pursuant to Government Code Section 913 and
sY2 0 09,
915.4. Please note all "warnings".
AMOUNT: UNKNOWN -IT b1l S O I, �-�
1ARTI M-1- LU Q��
CLAIMANT: JOY STOWELL
ATTORNEY: UNKNOWN DATE RECEIVED: NOV. 23, 2005
ADDRESS: 16401 - 30l SAN PABLO AVENUE BY DELIVERY TO CLERK ON: NOV, 23, 2005
SAN' PABLO, CA 94806.
RECEIVED FROM RISK
BY MAIL POSTMARKED: MNAGEMM
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
NOVEMBER 23 2005
SOI:[N SW lerk
Dated: By. Deputy
II. MOM: County Counsel. TO: Cldrk of the Board of SupeMsors
(Wr'nis, claim complies substantially with Sections 910 and 910.2.
t
( ) 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. By. Deputy County Coun
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. ARD 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• tCLERK1,i;_:JOHN SWEETEN, -- Deputy Clerk
WARNING(Gov. code sectl"913)'
Subject to certain exceptions, you have only six(6) months from the date this notice was personally served or de osil
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"T'hi's 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; an.d that today I deposited in the United States Postal.. 'ce in Martinez, California, postage full
prepaid a certified copy of this Board Order and Nonce to Clainian addressed the c ainiant as shown above.
Dated: V *#e!" e v'o-JOHN SWEETEN CLERK
Deputy Clea
s
i
This warning' does not apply to claims which are not
subject to the California Tort Claims Act-such as actions
in inverse condemnation, actions for specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list is not exhaustive and legal
consultation is essential to understand all the separate
limitations periods that may apply. The limitations period
within which suit must be filed may be shorter or longer
depending on the nature of the claim. Consult the specific.-
statutes and cases applicable to your particular`claim.
The County of`contra Costa does not waive_any of its
rights under California Tort Claims Act nor does it waive
rights under the- statutes of limitations applicable to
actions not subject to the California Tort Claims -Act.
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SEP, -12-2005 09:27 CCC RISK MANAGMENT 925 335 1421 P-02
130ARDOF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTYONS TO CLADIANT
A. A claim relating to a cause of action for death or for m' Jury to person or to personal property or
growing crops shall be presented not later than six months after the accrual of the cause of
action. A claim relating to any other cause of action shall be presented not latter than one year
after the accrual of the cause of action.
(Gov. Code §911.2.)
B. Claims must be filed with the Clerk of the Board of Superyisors at its office in Loom 106,
County Administi"ation Building,651 Pine Street Marti=4 CA 94:55.3'
C. If claim is a district governed by-the Board of Supervisors, rather than the County,, the
name of the District should be filled in.
D. If the claim is against more than one public entity, separate claims must be filed against each
public entity.
E. Fraud. See penalty for fraudulent claims,Penal Code See. 72 at the end of this form.
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RE: Clain BY: Reserved for Clerk's filing stamp
EIVED
�UV, 2 0 05
Against the County of Contra Costa or jC
LE
0 SUPERVISORS
CONTPA r%
District)
{Fill.in the name)
-1 The undersigned cWmant hereby makes claim agmist.the County,of Contra Costa or the above-named
district in the sum of$ and Support of this claimrepresents as follows:
Ct*AA�0
1. When did the damage or (Give exact date and hour)
injury occur.
ou (01
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injury% 2. 'Where "d the e or injury occur? (Include city and county
-41 m
Ul where damage
.3 How did the damage or MiurY occur? (Give full details;use extra paper if required)
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4- Vlhat act or omission on the part of county or district officers, servants, or employees
IT mjury or damage.
caused the &VIA,
It
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5 0 count*or 0 c erss,S
4f , emplaretes causmg the
darnage or* Oury?
In! A.
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TOTAL P.02
SEP-12-2005 k 13:47 CCC R I EIS MANAGMENT 925 335 1421 P.02/02
6. What damage of mi uries or damages
and'
clai .ed.
Attach two es ' ates for auto damage,)
ava� #!eo
7. How was the amount claimed above computed? (Include the estimated amount -of any
prospectiveinir
ty or damaae.) LuvuAerAA4vLj4ut
$. Names .addresses of�it�.esses,doctors,and hos 'tals;
WA '401- 2, 0
9. L1st expenditures you e on accofant of this accident or a
DATE TWE AMOUNT
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.Gov. Code Sec. 910.2 provides"rhe clan shall be
signed by the claimant or by some person on his
behalf."
SEND NOTICES To: (Attornev)
Name and address of Attorney ) r
)
' is Signature)
Pd '
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} (Address)
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Telephone Telephone o. '
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PUBLIC RECORDS NOTICE:
Please be advised that this claim form.,or any claim filed with the County under the Tort CAct, is subject to
public disclosure under the Califomia Public Records Act. (Gov. Code, §9 6500 et seq.) Furthermore, any
attachments,addendums,or supplements attached to the claim form, including medical records; are also subject to
public disclosure,
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NOTICE,
Section 72 of the.Penal Code provides:
Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or
to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or
fraudulent clam bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a
period of not more than one year, by a fine of not exceeding one thousand dollars($1,004.40), or by both such
imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars
($10,000),or by both such imprisonment and fine.
TOTAL P.O2
How did the damage or injury occur?
The asphalt had fallen in and become uneven. Depending on the time of day and direction of the
sun,the visibility of the sinking street is undetectable creating a hazard. It creates an optical
illusion created by heat reflection, so that when I stepped on that area, I did not see that it had
sunken in,and any foot twisted and down I went. I was completely immobile. A neighbor that
was outside offered to lift me up,which he did.
#6. What damage or injuries do you claim resulted?
Right ankle with lateral tear and severe strain.
Physically this has been the most painful,ongoing,life altering incident/injury of my life.
The doctor recommended I take a week off work so that I could stay off my foot,but because I
am my sole provider and have financial responsibilities, I told him I could only take one day off.
And since I work in an office,I was able to set up a way to keep my foot up most of the day,
although I was, at times, in excruciating pain(and I have a high pain tolerance).
Since it is any right foot that is injured, it is unbearably painful to drive,because the position of
the foot in order to push down the accelerator and apply the brake is extremely painful. Needless
to say,this has caused another breach in my normal daily activities.
I usually work until 2 or 3 pm daily,then do a volunteer work which involves going to peoples
homes to which I need to drive. I drive to work daily but I have had to rely on others for my
other activities. It has caused me anxiety and depression problems because I have not had the
capacity to care for myself in a normal way. And to top it off,I have not been able to sleep in
my bed because I could not stand the pain of anything touching my foot, so my sleep has been
affected.
I had scheduled a weekend trip that I had to cancel because it would be too much walking in the
airports for me.
Yes,,this has totally disrupted my life and caused me much pain and suffering. I understand that
it takes a long time to be totally free of pain from others that have torn a ligament.
#9. List the expenditures you made on account of this accident or injury:
9/12/05 Dr Snyder $15.00 9/13/05 Off Work $120e00
9/16/05 Dr Snyder $15.00 9/22/05 Ankle Compress $ 9.78
9/20/05 Dr Snyder $15.00 9/25/05 Ankle Stabilizer $ 19.47
9/26/05 Dr Snyder $15.00
10/10/05 Dr Snyder $15.00
11/14/05 Dr Snyder $15000
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIMAI"4'T
A. A claim relating to a cause of action for death or for injury to person or to personal property or
growincy crops shall be presented not later than six months after the accrual of the cause of
action. A claim relating to any other cause of action shall be presented not 'later than one year
after the accrual of the cause of action.
(Gov,* Code § 91-1.2.)
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 9455.3.
n
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 clairn is against more than one public entity, separate claims must be filed against each
public entity.
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form.
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RE: Claim By: Reserved for Clerk's filing stamp
�S140 4__ C2�2u 1'AA9TC
ISDnA a 4-e,
Against the County of Contra Costa or Nut/
Q42
District)
(Fill in the name) ) osr ���
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum ol. and in support of this claim represents as follows:
1. When did- the damage or injury occur? (Give exact date and hour),
L 457 2,D0 9- 0 63 6
2. "where did the damage or injury occur? (Include city and county)
PPR OX !12- Mite— va� 511)t' .yC .- !ref
3. How did the damage or injury occur? (Give fall details;use extra paper if required)
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4.' what particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage?
Irg t I v je C 40 M L -e i
What are the names of county or district officers, servants, or employees causing the
damage or injury?
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6. what damage or injuries do your claim resulted? (Give full extent of u-juries or damages
claimed. Attach two o estimates for auto damn . K t, >/) Ms'
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7. How was the amount claimed above computed` (hiclude the estimated aniouu1t of any
prospective injury or damage.) A41114- -70 )UA-rel,;'
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8. Names and addresses of witnesses, doctors, and hospitals:
9. List the expenditures you made on account of this accident or injury:
DATE TIME AMOUNT .5hoo4q) pxlfi�
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Gov. Code Sec. 910.2 provides"The claim shall be
signed the claimant or by some person on his
beh "
SEND NOTICES TO: (Attorneys �
Name and address of Attorney ) Pr
)
a (Claimant's Signa
Wo
xp
V2
(Address)
Telephone No. Telephone leo. �,� � 7V—7g,�Oo
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PUBLIC RECORDS NOTICE,
Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act is subject to
r
public disclosure under the California Public Records Act. (Gov. Code, 55 6500 et seq.) Furthermore, any
attaclunents, addendums, or supplements attached to the claim fore., including medical records, are also subject to
public disclosure.
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NOTICE:
Section 72 of`the Penal Code provides:
Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or
to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or
fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail'for a
period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such
imprisomiient and fuhe, or by inhprisoninent in the state prison, by a fine of not exceeding ten thousand dollars
($10,000), or by both such imprisonment and fine.
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KEEP THIS SLIP FFO . REFERENCE
CLAIM
BOARD OF SUPERVISORS OF CONTRA. COSTA COUNTY CIO
BOARD ACTION: DEC. 20, 2005
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), given
Y-A Pursuant to Govenunent Code Section 913 and
915.4. Please note all "Warnings".
AMOUNT: .$250,00,0,.; # CA
CLAIMANT: .JASON STENSON
ATTORNEY: HARVEY M. LLETZ DATE RECEIVED: NOV, 239 2005
ADDRESS• 5315 COLLEGE AVENUE BY DELIVERY TO CLERK'ON.NOV. 237 2005
OAKLAND, CA 94618 -
HAND DELIVERED
BY MAIL POSTMARKED:
s
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN S W lerk
Dated: NOVEMBER 23, 2005 .. By: Deputy Y p Y
II. MOM: County Counsel, TO: Clerk of the Board of Suprvisors
41 pe g11
{ ''`This claim complies substantial) with Sections 910 and 910.2.
A Y
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).
mow ftn+
(V, Clan i timely filed. I amilud fliat it fA
iler: . . . Ccu�, t:,.. �*r"► ► �► ,,
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Dated. By. Q WrIZA Deputy County Coun:
AT
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. ORDER: By unanimous vote of the Supervisors present:
{ This Claim is rejected in full.
{ }
Other:
I certify that this is a true and correctpY
co of the Board's order entered in its,minutes for this date.
Dated' ►, ' JOHN SWEETEN, CLER4' aft e ut Clerk
Y
WARNING(Gov. code sect1pn 913)
Subject to certain exceptions, you have only six (6) months from the da a this no was personally served or deposit
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; mW that today I deposited in the United States Postal Service in,Martinez, California,postage full
prepaid a certified copy of this Board Order and Notice to Claimant addres d to the claimant as shown above.
Dated; ''' 00'400 ep-"4�/'
HN SWEETEN CLERK ►
Y Deputy Clea
3
i
This warning' does not app Y l to claims which are not
subject to the California Tort Claims Act-such as actions
in inverse condemnation, actions for. specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list is not exhaustive and legal
consultation is essential to understand all the separate
. p
limitations periods that may apply, The limitations period
within which suit must be filed may be shorter or longer
depending on the nature of the claim. Consult the specific
statutes and cases applicable to your particular*
claim.
The C'ounty' af dontraCosta does not waive•any of its
g
ri hts under California•Tort Cla"imisAct nor does it waive
rights under the. statutes of limitations applicable. to,x
g pp
actions not subject to the California Tort Claims 'Act,
.
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OFFICE OF THE COUNTY COUNSEL SII.VANO B.MARCHES!
COUNTY COUNSEL
COUNTY OF CONTRA COSTA ���
Administration Building -
,:~ , SHARON L. ANDERSON
651 Pine Street, 9 Floor CHIEF ASSISTANT
Martinez, California 945531229
a
# G REGORY C. HARVEY
(925) 335-1800 . ,, ��-���:
- a�1�1�1� ��, + VALERIE J. RANCHE
(925) 646-1078 (fax) `
I ASSISTANTS
co
December 2, 2005
Harvey M. Kletz
5315 College Avenue
Oakland, CA 94618
Re: Government Tort Claim of Jason Stenson
Dear Mr. Kletz:
We are in receipt of your government tort claim, which is currently being processed. If
your intent was to file a claim against the Superior Court of California or one of its employees,
please be aware that the Contra Costa County Clerk of the Board of Supervisors is not the proper
entity to serve. Any claims against the court or its employees should be directed to the Superior
Court Executive Office. Please see Government Code Section 915, subdivision (c) for further
directions.
Thank you for your attention to this matter.
Very truly yours,
SILVAN(B. MARCHESI
COUNTY COUNSEL
By: G
Monika L. Cooper
Deputy County Counsel
s
OFFICE OF THE COUNTY COUNSEL SILVANo B.MARCHESI
��,.�® �-"....~��,��+ COUNTY COUNSEI.
COUNTY OF CONTRA COSTA °° ��-tea �--- _��
Administration Building
SHARON L. ANDERSON
651 Pine Street, 9th Floor
-�
Martinez California 9453-1229 �� '� _ '` ,�=��-. ;* CHIEF ASSISTANT
GREGORY C. HARVEY
(925) 335-1800 $ �'�111� "� = f VALERIE J. RANCHE
(925) 646-1078 (fax) ASSISTANTS
Cniln
STATUTORY WARNING PURSUANT TO
GOVERNMENT CODE SECTION 911.3
TO: Harvey M. Kletz
5315 College Avenue
Oakland, CA 94618
RE: Claim of Jason Stenson
Please Take Notice as Follows:
The claim you presented to the Contra Costa County Board of Supervisors on November 23,
2005 was reviewed by County Counsel. The portion of the claim prior to May 23, 2005 was not
presented within six months after the event or occurrence as required by law.
Because you allege late discovery of the claim, the claim is "timely on its face" and will be
reviewed and acted upon by the Board of Supervisors within the statutory time period. To preserve
the rights of the County, its departments and employees to challenge the validity of your late
discovery claim, you are warned pursuant to statute that if your delayed discovery argument is
improper, your claim is late, and is being returned because it was not presented within six months
after the event or occurrence as required by law. (See Gov. Code, §§ 901, 911.2.)
Because the claim may not have been presented within the time allowed by law, we warn you
that to preserve your right in the event your claim is determined to be late,your only recourse at this
time is to apply without delay to the Contra Costa County Board of Supervisors for leave to present a
late claire. (See Gov. Code, §§ 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances,
leave to present a late claim will be granted. (See Gov. Code, § 911.6.)
Page 1
f -t
SILVANO B. MARCHER
COUNTY COUNSEL
By:
Monika L. Cooper
Deputy County Counsel
CERTIFICATE OF SERVICE BY MAIL
(Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664)
I am a resident of the State of California,over the age of eighteen years, and not a party to the within action.
My business address is Office of the County Counsel, 651 Pine Street, 9th Floor,Martinez, CA 94553-1229.
0 ,I served a true copy of this Statutory Warning Pursuant to Government Code
Section 911.3 by placing the document in a sealed envelope with postage thereon fully prepaid, in the United
States mail at Martinez, California addressed to Harvey M. Kletz, 5315 College Avenue, Oakland, CA 94618,
as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing
of correspondence for mailing. Under that practice,it would be deposited with the U.S. Postal Service on that
same day with postage thereon fully prepaid in the ordinary course of business.
I declare under penalty of perjury under the laws of the State of California and the United States of America
that the above is true and correct. Executed on:'MDfe. ylt 57-2."5 at Martinez, California.
Kathleen O'Connell
cc: Clerk of the Board of Supervisors (original)
Risk Management
Page 2
11/01/2005 13:59 CONTRA COSTA COUNTY CLERK OF• HE 4 915106553954 N0.491 D01
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS To CLAIMANT
A. A claire relating to a cause of action for dearth or for injury to person or to personal property or
growing crops shall be presented not later than six months after the accruals of the cause of
action. A claim relating to any other cause of action shall be presented not later than one year
after the accrual of the cause of action.
(Gov. Code § 91.1,2.)
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, MWinez, CA.94553.
C. If claim is against a district governed by the Board of Supervisors, gather than the County, the
name of the DiaTict 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 t-he end of this form.
RE: Claim By: Reserved for Clerk's filing stamp
I�
JASON S TB_N S QN
RECEIVED——,
Against the County of Contra Costa.or. )
NOV 2 3 20bi
DistTict) CLERK FMARD OF SUF�'F� '.^°' s,
(Fill in the n=e)
�� ' A Ces
.........
The undersigned claimant hereby makes claim against:the Comity of Contra Costa or the above-named
district in the sura of$2 5 0 , 0 0 0 and in support of this claim represents as follows:
1. W1ien dial the dm-nage or injury occur? (Give exact date and hour)
The negligence occurred on September 23 19
p 97 but was not
discovered until October 25, 2005 -
2. Where did the damage or inj
mury occur? (Include city and cotuity)
Martinez and other cities within Contra Costa County,
. How did the damage or injury occur? (Give full details; use extra paper if required)
SEE ATTACHED
4. VAiat particular act or omission on the part of county or district officers, servants, or employees
caused, the injury or damage?
SEE RESPONSE TO NO* 3
5 Wliat are the names of county or district officers,servants,or employees causing the
damage or injury?
Contra Costa County Clerk
11/01/2005 , 13:59 CONTRA COSTA• COUNTY CLERK OF THE 4 915106553954
NO.491 IP02
6. What dea-aage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto dainage-)
Loss of income in th e amount of $250, 000 plus emotional distress
7. How was the amount claimed, above computed? (Include the estimated amount of any
Prospective injury or damage.)
Details and eact amount are still being calculated
S. Names and adckesses of witnesses, doctors, and hospitals:
Not applicable
9. List the expenditures you made on account of this accident or injury:
T1 AM,.Ql LNT
Unknown at this time
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Gov. Code Sec. 910.2 provide "The claim shall be
signed by the claimant or by so e person on his
behal,
SEND NOTICES TO:. Attomeyl
Name and address of Attorney
HARVEY M. KLETZ (Claimant's Si turd)
ATTORNEYAT LAW 14ARVEY M*KL
ATTORNEY AT
5315 COLLEGE AVENUE an, -c(0-'%r-LAVF UE
OAKLAND, CA 94618 ro OAKLANO(We9*18
Telephone N®.
..-( 510 ) -f,55-2143 Telephone No.
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PUBLIC 1 CORDS NOTICE:
Please be advised that this claim form, or any claim filed with the County tinder the Tort Claims Act, is subject to
public disclosure tinder the California Public Records Act. (Gov. Code, §5 6500 et seq.) Furthermore, any
attacbments,addendums,or supplements attached to the claim,form, including medical records, are also subject to
public disclosure.
&some a 9946swevesp 101bussesS,a sumessame a spas mods I what
NOTICE:
Section 72 of the Penal. Code provides:
Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or
to any county, city, or district board or officer, a.-uthorized to show or pay the same if genuine, any false or
fraudulent claim, bill, account vouther, or writing, is punishable either by imprisonment in the County jail for a
period of not more than, one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such
imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten tbousand dollars
($10,000), or by both such imprisonment and tide.
3. On September 23, 1997, Jason Stenson,, Sr., plead guilty to a misdemeanor Health and
Safety Code Section 11350[b] violation. At that time,, the Clerk of the Court *incorrectly
entered the plea as a felony. Subsequent to September 23, 1997, Mr. Stenson has been
unable to receive numerous jobs as a result of employer's determining that he, in fact, had
a.felony conviction which was erroneous.
•
14
LAW OFFICES OF
HARVEY M. ISL.ETZ
EMAIL: 5315 COLL.E?GI AVENUE TEL(510)655-7141
hkletz@aol.com OAKLAND,CALIFORNIA 94618 FAX(510)655-3954
November 22, 2005
Mal
gn
t1E
TRANSMITTAL MEMO} wov
�
To: Clerk CLERK CP
Contra Costa County .Board of Supervisors
651 Pine Street, Room 106
Martinez, CA 94553
SUBJECT: S TENS N , C WTKA COSTA CGUIV'TY
ENCLOSURES: ORIGINAL AND ONE (1) COPY OF CLAIM
REQUESTED ACTION:
[ ] Enclosed for your information. [ ] Please telephone me after reviewing
the enclosed.
[X] Please file original(s) and return endorsed [ ] Please telephone my office and make an
copies. appointment.
[ ] Enclosed is a check for fees. [ ] Please have the Judge sign.
[ ] Please record original and return copies. [ ] Enclosed is a check.
[ ] Instructions/Remarks
Thank you.
Sincerely yours,
r,
Denise Taylor
Assistant to HARVEY M. KLETZ
enclosures
r r
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: DEC. 20, 2005
Claini 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. j notice of the-action taken on your claim by the
Board of Supervisors. (Paragraph IV below), give]
ze Pursuant to Government Code Section 913 and
.. Y.
915.4. Please note all "Warnings".
LJ
P
AMOUNT: AM k-:THE JURISDICTION OF
SUPERIOR COURT
CLAIMANT: DANTE AND EVELYN . ALCANTARA
ATTORNEY: ROBERT A. -MILLER DATE RECEIVED: NOV, 232 2005
• HERMELIN BY DELIVERY TO CLERK ON: NOV, 23, 2005
ADDRESS: STERNBERG & COAD .
540 LENNON LANE •
. REEK CA 94598 NOV. 22, 2005
WALNUT C BY MAIL POSTMARKED:
FROM: Clerk of the Board of Supervisors' TO: County Counsel
Attached is a copy of the above-noted claim.
. JOHN S WEET N C rk
Dated: NOVEMBER 23, 2005 I
MONNOWNSMEW� B Y�• Deputy
_....__
II. #kO--M: County Counsel. ,: TO: Clerk of the v's
Board of Superors
(L41rhis, claim complies substantially with Sections 910 and 910.2.
This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
O Other:
Dated.
�.-,;, .�-,�"'-�� : Deputy County Coun;
. ,� B
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. ARD ORDER: By unanimous vote of the Supervisors present:
( This Claim is rejected in full.
O Other:
R
I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.
Dated,, � SWEETEN,� OHN D e yClerk
WARNING(Gov. code secti 913)
Subject to certain exceptions, you have only six(6) months from the date this novwas personally served or deposit
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 full
prep co aid a certified of this Board Order acid Notice to Clainian addressed to the claimant as shown above.
1✓'Y
'OVqHNDated: SWEETEN CLERK ut Clei
r
i
This to not warning does apply claims
which are not
subject to the California Tort Claims Act-such
J as actions
in inverse condemnation, actions for. specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list! is not exhaustive and legal
consultation is essential to understand all the separate
p e
limitationsperiodsma a l that . Ther limitations�' apply. period
#a.1
w1min which suit must be filed may be shorter or Ionizery
depending on the nature of the claim. Consult the s ocific .
, I
statutes and cases applicable to your particular claim .
The Countyof Contra Costa does not waive ..any of its
rights under Californi.a**Tbrt Cliiim i Act nor does it waive
rights under the. statutes of limitations applicable t
actions not subject to the Califom' 'I'a Tort*
Claims 'Acts
c .
t
3
r
1
VM
R
'6d '
E
I Ivil RE,rub
S
TEBERG & COAD-BERMELIN LLFNov 2 3 Z U U
ATTORNEYS AT LAW
CLLR SRR��" � T��
540 Lennon Lane 0 `�R ,}y� p
Walnut Creek,CA 94598
(925)946-1400
Facsimile(925)932-6986
November 23, 2005
Clerk of the Board of Supervisors
651 Pine St.
Martinez, CA
Re: Dante & Evelyn Alcantara
Property located at 127 Harris Circle, Bay Point, CA 94565
To Whom It May Concern:
This letter is submitted as a Claim under Government Code §900 et seq. Per discussion
with James Kennedy, Redevelopment Director, the Alcantaras were directed to submit a claim in
a letter to the Clerk of the Board of Supervisors.
On November 9, 1994 Dante and Evelyn Alcantara entered into an agreement with the Contra
Costa County Redevelopment Agency through which the Agency loaned Twenty Five Thousand
Two Hundred Dollars ($25,250)to Mr. and Mrs. Alcantara. After approximately 10 years,the
Alcantaras decided to sell their home. In compliance with the Resale Restriction Agreement, the
Alcantara's noticed the Agency of their intent to sell their property, and the Agency exercised its
option to purchase. An eligible purchaser then assumed the full amount due, which included
interest at the close of escrow on May 27, 2005 as a new loan in the amount of Fifty Thousand
Four Hundred Eighty Dollars ($50,480).
Contrary to the Resale Restriction Agreement,the Agency failed to provide to the Alcantaras the
fair market value pursuant to the Agreement's Restricted Resale Price section titled Selling Your
Home After 10 Years. Furthermore,the Agency failed to forgive or cancel repayment of the
$50,480 (initial $25,000 loan plus interest) once the new eligible purchaser assumed the loan
pursuant to the Agreement's Eligible Purchaser section titled Sale To An Eligible Purchaser.
The names of the public employee causing the Alcantara's injuries are James Kennedy - Deputy
Director- Redevelopment; Dennis M. Barry, AICF, Community Development Director; Sara
Welch and Linda Hoover Baty.
M A6
Clerk of the Board of Supervisors
November 23, 2005
Page 2
The Alcantaras' claim as of this date is in an amount that would place it within the unlimited
jurisdiction of the Superior Court. The claim is based on the injury, damage, and/or loss in the
amount specified above. All notices should be sent to my office at the above address.
Sincerely,
STERNBERG& COAD-HERMELIN, LLP
ROBERT A. MILLER
RAM:dfh
cc: Dante and Evelyn Alcantara
R
4 CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY M
BOARD ACTION:. DEC 20, 2005
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), gives
Pursuant to Government Code Section 913 and
915.4. Please note all "Warnings".
AMOUNT: UNLIMITED CIVIL
CLAIMANT: JAMES W. BEALL, JR. ;
ATTORNEY.. PETER W. MANION DATE RECEIVED. NOV. 289 2005
HAKEEM, ELLIS & MARENGO R CLERK*
ON:NOV. 28, 2005
ADDRESS. BY DELIVERY TO C .
3414 BROOKSIDE ROAD, #100
STOCKTON, CA 95219 NOV. 20 2005
BY MAIL POSTMARKED:
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN SWEET 1
Dated: NOVEMBER '28, 2005 By: De ut
p y
II. FtOM: County Counsel, = T4: Clerk of the Board of Sup ervi rs
(0<This claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
O Other:
w
Dated: By: 61 6;� Deputy County Coun.,
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2)
O Claim was returned as untimely with notice to claimant (Section 911.3). •
IV. ARD ORDER: By unanimous vote of the Supervisors present:
( This Claim is rejected in full.
O Other: '
I certifythat this is a true and correct*co of the Board's Order entere its minutes for this date.
copy
Date HN SWEETEN CLERI , De ut Clerk
y �. y
WARNING (Gov. code sects 913)
Subject to certain exceptions, you have only six(6) months from the date this notice was personally served or deposit
in the snail 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 full
prepaid a certified copy of this Board Order and Notice to Claimant, ad to the claimant as shown above.
Dat . . ���
ed. spa OHN SWEETEN, CLERK�y Deputy Clei
t
f
This warning does not apply to claims which are not
subject to the California Tort Claims Act-such as actions
in inverse condemnation, actions for. specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list! is not exhaustive and legal
consultation is essential to understand all the separate
limitations periods that may apply. The limitations period0
within which suit must be filed may be shorter or longer
depending on the nature of the claim. Consult the specific.
statutes and cases applicable to your particular'claim.
The County of Contra Costa does not waive any of its
rights under Californi#`Tbrt Claims Act nor dines it waive
rights under the. statutes of limitations applicable to
actions not subject to the California Tort Claims 'Act,
11/22/2005 16:00 CONTRA COSTA COUNTY CLERK OF THE 4 912094743654 NO.554 POI
130A." OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAJMANT
A. A claim relating to a cause of action for death or for I'lliury to person or to personal property or
growing crops shall be presented not later than six months after the accrual of the cause of
action. A claim relating to any other cause of action shall be presented not later than one year
after the acertml of the cause of action.
(Gov. Code § 911,2,)
B. Claims must be filed with the Clerk of the Board, of Supeivisors at its office in Room 106,
County AdministTation Building, 651 Pine Street,Martinez, CA 945531.
C. If clairn is against a district govenied by the Bo d. of Supervisors, rather than the County, the
name of the District should be filled.in.
i
D. If the claim s against more them one public entity, separate claims must be filed. against each
public entity.
E. Fraud. See penalty for fvaudulent clwwms,Penal Code Sec. 72 at the end.of t1-.is form.
unsew voymonownso wwwwoosoftess N eggs$809000008*680 age 6 sawwwwonownwenow a own*****too
RE: Claim By, Reserved for Clerk's filing stamp
James W. Beall, Jr.
R E C E V EIIL�0
Against the County of Contra Costa or NOV 2 8 ZOO—
District)
CLERK i-",r7i'Itt 11211 0 h S
6 R,A t
(Fill in the n=e)
The undersigned, clairaambeneb against
unlimitinmakes claim t the County of Contra Costa or the above-named
districti".1 the sum of$ civil I and in support of this clsiin represei:ias as follows:
I. When did the damage or injury occur? (Give exact date and,hour)
May 24, 2005 at approximately 3:25 p.m*
2* Where did the d,=.age or injury occur? (Include city and county)
Marsh Creek Road at intersection with Camino Diablo in unincorporated Contra
Costa Cdunty, California
3. I-low did the damage or injury occur.) (Give full details;use e=a paper if required)
The motorcycle on which claimant was riding collided with a trailer that was
being pulled by a Peterbilt tractor.
4. What particular act or omission on the part of county oTdisuict officers, servants, or employees
4
cause,d the inymy or damage? See Attachment A
5 What are the names of county or district officers,servants, or e1uployees causing the
damage or in wy?
Unknown
16:00 CONTRA COSTA COUNTY CLERK OF THE 912094743654 NO.554 P02
6. What dmnage or i,nju ,es do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto daniage.) So far as is presently known, injuries to
both legs, the right hip, both arms, head trauma, including brain damage, pain and suffering, past
and future medical bills, disfigurement, permanent disability, loss of enjoyment of life, lost
d futur�owv w asid diminish 4 earnng capacity.past ani es, C7. was the amount ralmed anove computed? (Include the estimated amount of any
prospective mJ ury or damage.}
Not required pursuant to Government Code Section 9100
9. Names and addresses of witnesses9
doctors and.hospitals.,
Not required pursuant to Government Code Section 910,
9, List the expenditures you made on acco-Luit of this acoident or
1171jury,
DATE TME AMOLNT
Not required pursuant to Government Code Section 910.
Wonsmaneffaff a above a a ON Guam**of#**see 0461014 sonvewwwwral OWNWEN*ones
Gov. Code See. 910,2provides"The claim shall be
signed by the claimant or by some person on his
behalf.''
SEND NOTICES TO,. ('Attorney)
Name and address of Atiorney
Peter W. Manion, Esq.
st
Hakeem, Ellis & Marengo By Attorney
3414 Brookside Road, #100
. Stockton, CA 95219 )--Claimant. 1888 Mustang Court
(Address)
Concord, CA 94521
Telep.hon,e No. (209) 474-2800 (925) 689-3976
a ) Telephone No.
swunhawas mango Woos 0 WWN&WftW*V#ease*0 80668840*80"a 601888088600808 04668895 so*of Wynannums
4
PUBLIC RECORDS NOTICE#
Please be advised that this claim form,or any claim filed with the County under the Tort Claims Act,,is subject to
public disclosure under the Califonfia. Public Records Act. (Gov, Code, §§ 6500 et seq.) Furthemore, any
attachments, addendums,or supplements attached to t claim forin,including medical records,are also subject to
public disclosure.
a a a a a a a a 0 a a a 0 W V a a a to a 0 0 a a a 0 a 0-2 a a a a a a a S a 0 a 9 0 6 6 W a a a 8 8 0 6 5 V 0 V i a a to V 6 a W a 0 a 0 1
NOTICE*
Section 72 of the Penal Code provides:
Event'Person W110, WWI intent to defraud,presents for allowanoo or for payinent to any state board or officer, or
to any county, city, or district board or offficer, authorized to allow or pay the same ifgenuine, any false or
fraudulent claim, bill, account voucher, or writing, is punish,4ble eitlier by imprisonment in the County jail for a
period of not more than one yoar.* by a fine of not exceeding one thousand dollars ($1,000.00), or by both such
imprisonment and fine, or by.imprisonment in the state prison, by a fine of not exceeding ten thousand dolim
($10,000),or by both such imprisonment and fine.
ATTACHMENT A
The design and/or construction of the roadways in the area
of the intersection where the accident occurred constituted an
unreasonably dangerous condition for motorists, such as claimant,
who are traveling on said roadways with due care.
Moreover, this dangerous condition, which is likely to cause
collisions between vehicles, is not reasonably apparent to a
person exercising due care and, therefore, the public entity was
negligent by failing to post traffic and/or warning signals,
signs, markings, and/or devices to warn motorists of the
dangerous condition and to warn of the need to decrease speed.
Said failure constitutes a dangerous trap to motorists in the
area, because it is not apparent to motorists continuing
northbound on Marsh Creek Road, who have the right-of-way, that
motorists traveling southbound on Marsh Creek Road may be making
a left turn directly in violation of the northbound motorists'
right-of-way. This dangerous condition creates the probability
for accidents and resulted in the accident giving rise to this
claim.
The public entity has had actual or constructive notice of
this dangerous condition and has had further actual or
constructive notice that the aforementioned design is no longer
in conformity with a plan or design or a standard that reasonably
could be approved, and has existed in that state for sufficient
time for the public entity to have remedied the condition.
ra
PROOF OF SERVICE
[C.C.P. 1013(a)]
2
STATE OF CALIFORNIA
3 )ss.
COUNTY OF SAN JOAQUIN
4
11, Colleen Davis, declare that I am over the age of eighteen and not a party to this action. My
5 business address is Hakeem,Ellis&Marengo, 3414 Brookside Road, Suite#100, Stockton, California
95219,which is located in the County of San Joaquin where the service described below took place.
6
On the date below,at my place of business at Stockton,California, a copy of the following
7 document(s):
8 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT
AND CLAIM FORM
9
was placed in a sealed envelope addressed to:
10 Clerk of the Board of Supervisors
11 Room 106
County Administration Building
12 651 Pine Street
Martinez,CA 94553
13 [x] BY U.S. MAIL: I placed the above documents in a sealed envelope for deposit in the United
14 States Postal Service,with first class postage fully prepaid, and that envelope was placed for
collection and mailing on that date following ordinary business practices as indicated above.
15 [] BY FACSIMILE TRANSMISSION: I transmitted the above documents by facsimile
16 transmission to the FAX telephone number listed for each party above and obtained confirmation
of complete transmittal thereof.
17 [] BY CAUSING PERSONAL SERVICE: I placed the above documents in a sealed envelope. 1
18 caused such envelope(s)to be handed to our messenger service to be delivered as indicated
above.
19
BY OVERNIGHT EXPRESS: I placed the above documents in a sealed envelope. I caused such
20 envelope(s)to be delivered by Federal Express to the above address(es)by overnight express.
21 1 am readily familiar with the business practice at my place of business for collection and
processing of correspondence for mailing with the United States Postal Service. On the same day that 1
22 place a sealed envelope in the internal mail system of Hakeem, Ellis&Marengo for collection and
mailing, it is deposited in the ordinary course of business with the United States Postal Service with first
23 class postage fully prepaid.
24 1 declare under penalty of perjury under the laws of the State of California that the foregoing is
true and correct. Executed on November 23, 2005, at Stockton, California.
25
26 Colleen Davis
27
28
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION.
. DEC* 20, 2005
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), giver
Pursuant to Government Code Section 913 and
915.4. Please note all"Warnings".
AMOUNT: $10,000-00
CLAIMANT: LAMOS W. STURGIS
#2005018962 Q-MODULE #5
ATTORNEY: UNNOWN DATE RECEIVED: NOV. 289 2005
ADDRESS: BY DELIVERY TO CLERKON: NOV. 28, 2005
MAIN DETENTION FACILITY BY MAIL POSTM D.
NOV, 249 2005
1000 WARD STREET,
FROM: Clerk ofWto u ' ors TO: County Counsel
Attached is a copy of the above-noted claim.
. JOHN S WEE EN, erk
Dated: NOVEMBER 28, 2005 .. By: Deputy
3' p y
II. MOM: County Counsel, .= TO: Clerk of the Board of Supe isors
{ his claim complies substantially with Sections 910 and 910.2.
{ ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
{ ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3),
{ ) Other:
�
Dated.* 4 By. Deputy County Coun;
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. ARD 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.
Date ' .. OHN SWEETEN, CLERK , D ty Clerk
WARNING(Gov. code sectio 913
Subject to certain exceptions, you have only six (6)months from the date'this n i,,)cwas personally served or deposit
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.
f 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; mW that today I deposited in the United States Postal Service in Martinez, California, postage full
prepaid a certified copy of this Board Order and Notice to Claimant c r ss to the claimant as shown above.
Dated., O►HN SWEETEN, CLERK. Deputy p y C
1
I
This warning does not apply to claims which are not
subject to the California Tort Claims Act-such as actions
in inverse condemnation, actions for. specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list is not exhaustive and legal
consultation isessentialo understand all thcons t e se state
. p
limitations periods that may apply. The limitations Penod
within which suit must be filed may be shorter or longer
depending on the nature of the claim. Consult the specific
statutes and cases a licable toyourparticular''claim.
pp ...
The Countyof Contra Costa does not waivean of its
Y
rights under California-'Tort CI'a'im 0 Act nor does it waive
rights under the. statutes of limitations applicable to
actions not subject to the California Tort Claims Act.
R.
'M
1aBOAT 'SJPR
n
OR. OF OO1�TRA�CO►STA=��
.
ars . c z 5IL
To.JC Af-B4 N
T
a s gelatin o.causes.of.action.f r_ - {
o death or:for.In u
$ to erson or to+ ersanalo a r5-
r :
�:) rY P
,x P
d wh1, r
ch accrue=an or_ f r
be o e:December.,3
.l , 987
P .�..;must
_ _ � erg: rese
nted
Cr
;. -' not��ater
F
mer he.ac zvL
crual afhe cause:ofactlon. la�m
s gelatin to,rcauses:rof: on for td. th
arson v .r.,
_ , lg ea or for��J to
o to. ersonal roper t,
e or. owi cr
P .,P ,P ,P rtY and whichaccrue on or aider Manu 38
a 1 :1
op
S 'rn
_arY � � u
r
.,,,.... .. ,
esente n
d of mater,th
an, � , ,
six mon
the.:af +er,; : -,-�offif er
P _ the racci�u .of he
cause�of,act�on. . 1a1ms� ��el tin :r. � 3
a o
t ,f.
.. (c �: i..,g .fit ' p7 .. y;.. .,: .,:.. 2. y v •:'.. :,, �z'
cause_of'action.,must.be, re t
rented not later
n pane Year
ager
P theccrual.of he:cause of:actlo .
i't bode 1 .2.�
S
y
• .,: 7-
C aims must.be fihed
with the lark
of th
e Board
-dfS, ervzsors at its;office in ROOM I�6 noun
mz
,
P tY
nstratior .Bulldn 1: me 5tre
Pl
et,M net,°CA;�94 3,
.
�a1�1111"
oP' -
r;.
c
s:ra
ahnst a.
}
r .
If
distr� .. .r
.a �avern �=�� . : y. ' ��
ed b the Br
oard of Su: ervlsor r
s ather than the tie Lname of
thestrct
should be fild}zn.
Iv
D.
Ifthe ca�an
s alnst
or ahan one, ublxc ent
P ty, separate rclalrnsmust.be filed y, :glnst:each pbh:c
entity.
E.
.r
Fraud. 5ee enalt � r
y o fraudulent clams Venal Code Sec. 2
P at the end of this form.
. lahn
Y Deserved.for clerks fifil*atarn
,. P
E
:a�r
nrst flit t'noun of Contra costa,or
`0 - 8 l00,
r SI tn. t
- ,..
1� In�Ilal't'Ie� LERK 00A
in
' Q' '�w �' #S
":ft, 0
� .
'.
e LiT�dersi. Ile •
dla�mant hereb ' : ;
_ -�na�es cla�rn�� � �� � : ,
Y alnst the:Conn of Contra F t
ty os a or the above Warned dstnct
►�
n:.the.: � N. F �� �-rte` ,•:
sum of and fn,support of this'clalrn re. relents as follows:
P
W, :did e , E_
th damage.fir �u orccur? 'rive exact date
� ( and hours
Z 'fhere'-did the 4=4, e.or in•u -occur? (Includeg city and'county}
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3. ow did-the damage or injury occur? Give fu11 details• use extra a er if re it
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DAMT AOS
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o .'Code Sec. 1Z,
_ prudes Thelatm must be
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NOTICE
Section 72 of the Penal Code provides:
Every,person w.ho,,with intent to-defraud,� resents for-aman
p ce or the°payment to.any state boa or.'officer,onto any
county,city,nor.district board or officer,',,authorizedto allow or ply the same if enuine an false or."
g y fraudulent cn,bill,account,
voucher,or writing,is pwaishable either by imprisonment in he coon 'ail for •od of n m
tyj pen of ore than one year,by a f ne of not
exc g:one thousand 0.1,000),or by both such imprisonment and fine,or by imprisonment in the state n"so 'b a fine of not
P � y
exceeding ten.thousand dollars 010;000),or by both such imprisonment and fine.
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