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Home My WebLink AboutMINUTES - 01082008 - C.25 (13) 17 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY P,, 20ir BOARD ACTION: JANUARY08, 2008 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 California Government Codes. I X&A ) you is your notice of the action taken on your claim by the Board of DECJ Supervisors. (Paragraph IV below), 2007 - given PprSuant to Government Code AMOUNT: $9,000.00 COUNTY COUNSEL Section 913 and 915.4. Please note all tIARTINEZ CALiE "Warnings". CLAIMANT: MARK D. GUILLORY ATTORNEY: UNKNOWN DATE RECEIVED: DECEMBER 03, 2007 ADDRESS: 5032 NM STREET, BY DELIVERY TO CLERK ON: DECEMBER 03, 2007 RICHMOND, CA 94804 BY MAIL POSTMARKED: NOVEMBER 30, 2007 FROM: Clerk of tlhe Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DECEMBER 03, 2007 JOHN CULLEN, Dated: By: Deputy k�� T.I. FROM.: County Counsel TO: Clerk of the Board of S pervisors ( 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: -?,07 By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V BOARD ORDER: By unanimous vote of the Supervisors present: ( 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. Date /8'AVAHN CULLEN, CLERK, ByzA6F�4- Deputy Clerk WARNING (G v. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that i. am now; and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated._ e-P. 4wd'JOHN CULLEN, CLERK By Deputy Clerk 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 U BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY 3 0 ),2-> INSTRUCTIONS TO CLAIM- A claim relating to a ca-use of action for death or for injury to person or to porsonal property or au grDiving 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 s'nall be.presented not later tta-M one year after the accrual of the cause of action. (G-ov. Code § 911.2.) Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, Counts,Administration Building, 651 Pine Street,Martinez, CA 94553. 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. If the claim is against more ftm ane puniiu eaLL, sepa�atc cl^-imv =„ft be fi1Pd against each. public entity. Fraud See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form.. [[!■t[[t!![[![[[[[!t t t [t!!![9 t i It K C t![[E!!i[![!a t G C EC.0 t[t[I[l[!R! a[![[[t t L[[1 E: Claim By: Reserved for Clerk's filing stamp Q DECEIVED against the County of Contra Costa or ) DEC 0 3 2001 56-rAistriCt) ICLERK BOARD OF SUPERVISORS / CONTRA COSTA CO. Fill is the name) ) lei-� the undersigned claimant hereby makes claim against Lhe CounTy of Contra Costa or the above-named I strict in the sum of and in support of this claim represents as follows: 1. When did the damage or in Give exact date and hour) ] I --;)LO � ' jar occur?� ( 5' 7c� ly �� 2. Where did the damage or injury occur? (Include city and county) 'l)lt l h�er�Sl'<�t C>Y1 C>� r\ CLC 3. How did,i�he dam ae or injury occur? (Give full details;use extra paper if required) '`� Wc� ,S .54(V%11ne U � bxjci \ 4. 7� particular act or osni.ssi.an on the part of county or district officers, se ants, or emplo5fees` c used the iri or dama>?e? G+�,ct �' l i \' 1�' � '`'� �`(-� She r L.� �.ol�(�ex-5 JAY � S �. v I \C 6 CU �- LA r(fC A a V'1� tib�C`�\� � >'�-tL �►/�..L �t� `� \S �'�-^ v'� 5 What are the names of county or district officers, sen'ants, or employees causing the damage 07 injury? cora, rot- Cg 546L L -L �'1k r?.- Cl �� - - o� �.400psu_ e dt -s cver�- '-lam e� 6 ?�.47 �j e or injuries do your claim resulted? (Give full extent of injuries or damages What damaba - -claimed. -Attach-two estiznates f 't'\ or auto damage.) C) . Cl How`was the amount claimed above computed? (Include the estimated amount of any prospective Laiury or damage.) i �,_ �l, Pz t(l n Lt :5 ��r 1 1� �'�-��:� Names and addresses of witnesses, doctors, and hospitals: �nvzt 4 6r\ A a,- r Q ce- �! List the expenditures you made-on account of this accident or injury: 4 m DATE TIME AMOUNT .� [ ■[E C i a�v C!■C C it E!11E E■[C E E E t!!■■ !it [[!■[[!l 1 l![[[!t[ 9221111121122 f[E[!!RIERMEN[1 .Gov. Code Sec. 910.2 provides "The claim shall be signed by the claimant or by some person on his behalL" SEND NOTICES TO: (Attorney) 1 r I\ame and address of Attorney ) �� (Claimant's Si . } T^\S Telephone-No. - } Telephone o. ■[![![[[[[I I[RKRZER BEER E C G 2 Maze r I I[I I I I t![I![[!E[[[![[![[![![![[[[f[!![[!E!! E[[I![![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, ss 6500 et seq) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■!!![t[[![[[[!E![[■![[!! ■ ■ In![[![[It!!I It E■!E E!![it!![ NO'T'ICE: Section 71 of the Penal Code provides: Every person v,,ho, 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 w alloor pay the same if genuine, any false or ffi 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,DD.DO), or by both such imprisonment and Erne, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. .. (o3v/3 /P CONSENT TO RELEASE MEDICAL INFORMATION I 0411 6WIory authorize Am4cx POr c btuc-e.. DiL D ' • (Name of Patient) (Provider of Health(fare) �$lpJ �Q3-�355 to disclose to the bearer, who represents the County of Contra Costa—Risk Management Division-and/or designated copy service, all medical information to substantiate a claim initiated by me. I hereby consent and request that the bearer be permitted to examine and obtain copies of all, hospital and medical records of every sort and kind, interview doctors and other attendants regarding all matters relating to examination, diagnosis, care and treatment of myself. I understand that this Consent for the Release of Medical Information will remain valid cancelled by me. I hereby acknowledge that I have received a copy of this Consent for Release of Medical Information. It is understood that a Photostat of this authorization is as valid as the original. Date: V Signed: Address: l A $� q Or (51.01 (Conservator or Guardian) Date of Birth: 1 011" �_6_(0 1 Social Security No. _S)5 fL'13 _q CU .j cr crO C=) �o ow Cv u :D F¢ C*ID O G LU o •� C� o = LU (, ¢- �` O O C m Y O w QJ Q � L UN0 �z Olt, - d a o