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Home My WebLink AboutMINUTES - 12162008 - C.30 (8) APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY , CALIFO/IR--NIA ARD ACTION: Application to Filer Late Claim �' NOTICE TO APPLICANT pp LIC T Against the Count Routing ° Qg Ei� g y, g dopy of this document mailed to you is your Endorsements, and Board Action ) no ice of the action taken on your application by (All Section References are to ) NOV 14 2008 the Board of Supervisors (Paragraph III, below), California Government Code )COUNTY COUNSEL given pursuant to Government Code Sections 911.8 M MARTINEZ CALIF. and 915.4. Please note the `WARNING' below. Claimant: Kl m-qlle� Attorney: Amount: Address: j5g7 jf By delivery to Clerk on: R.(C.G�fhOD1l� CA, Date Received: t MOV. lt{', oQPa By mail, postmarked on 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Later Claim. DATED4a. 14-f 0-00� DAVID TWA, Clerk, By: DEPUTY FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6) ( The Board should deny this Application to File Late Claim (Section 911.6) DATED: �2'�'� SILVANO B. MARCHESI, County Counsel, By:MCO- -I DEPUTY 1II. BOARD ORDER By unanimous voter of Supervisors present (Check one only) ( ) This application is granted (Section 911.6). (� This application to Filer Late Claim is denied (Section 911:6) 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATE A" .��i f"� DAVID TWA,Clerk, By: DEPUTY WARNING (Gov. Code 911.8) If you wish to file a court action on this matter,you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4(Claims presentation requirement),See Government Code Section 946.6. Such petition must be filed with the court within six(6) months from the date your application for leave to present a late claim was denied. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately- IV. FROM: Clerk of the Board TO: (1) County Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document,and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance)with Section 29703.. DATED: Ute•/ Z"J',/ DAVID TWA, Clerk, BY: DEPUTY V. FROM: (1) County Counsel (2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator,By: APPLICATION TO FILE LATE CLAIM i N c3,:17:ir, 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. 1 y �. �,�� C-- cam.t �`t Cc �� 1�=,�, � � BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAHAANT A. A claim relating to a cause of action for death or for injury 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 accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each. public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ........aa.....a...............■s...............................R as a..a.INN.■ .I RE: Claim By: Reserved for Clerk's filing stamp VA RECEIVE Against the County of Contra Costa or ) NOV 1 4 7068 District) CLERK BOARD 0r SUPLRv1SORS (Fill in the name) ) CONTRA CO'SIA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 14,2 S R. and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) uv-1 kDoo 2. Where did the damage or injury occur? (Include city and county) \55Q -:�O S1- ��ehrc�a +ucuG�ki01 mVrc. Cobi CO3 3. How did the damage or injury occur? (Give full details; use extra paper if required) 4WV-d QiL2. Cj vtrE b�r�� hC1 �� 4. Wh`a p auhaLr omission4thart`x of cot n or district officers, servants, or employees caused the injury or damage? �rsl�ecA-L mv1 %}o�e dD�n b�cav`� w4 S1-or-e, a,r.ct Z recatV-ej CL Q k-ir s�tkincl mv+ p�znY;c4- �.5(ti„S 5ug(2zrC,l,e� �-rtil he.wc-� 5 What are the names of county or district officers ervants, or employees causing the damage or injury? �1 n o {V v\Chef-+C\. 1 � , 6. 'WL-�-t danage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) p,,, pyo 7`'�� }I7 ; r�� eLuawr�wsnA p�c�d a .n(lw� kx5eaht 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 . ..akin RONsonsamaRas ameans anoo......oxmossommenasRange sommoaaa moaaaaaaam a a Kaaammmaaaol ) .Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) ) Name and address of Attorney ) (Claimant's Signature) (Address) Telephone No. ) Telephone No. �� M5aaaa.....2aa2aaaaa0a2a0a2 a a a 2a■a aaaaaaaoa■■aaaaaaa as aamaaootaaaa aaaaaa MEN a.......1 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 California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ..mks man on,aa.aaaman a aaam a ■aao■■aaaaaaoaamaa an a Rag aaaaaaaoaaa•aaaoataa•■a■as a■aama Komi 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 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.