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HomeMy WebLinkAboutMINUTES - 05222001 - C.8 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACT10May 22, 2001 Claim Against the County, or District Governed by 1 the Board of Supervisors, Routing Endorsements, I NOTICE TO CLAIMANT and Board Action. All Section references are to I 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 �� �T� FIIM pursuant to Government Code Section 913 and d 915.4. Please note all "Warnings". AMOUNT: Unknown APR 2 0 2001 COUNTY COUNSEL CLAIMANT: Anna & Edwin White MARTINEZ CALIF. ATTORNEY: None DATE RECEIVED:I-Ng* 19, 2001 ADDRESS: 98 Crivello Ave BY DELIVERY TO CLERK ON: 19, 2001 Bay Point, CA 94565 BY MAIL POSTMARKED: I. FRON1 Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN Si EL4, Clerk Dated: May 20, 2001 By: Deputy NU II. FROM County Counsel TO: Clerk of the Board of Supervisors ( 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: �'3r D By: Deputy County Counsel M. FROM Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's OrdeNntered iits m' es f this date. Dated: a JOHN SWEETEN Clerk, By eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claiman , ddres d to t clai ant as shown above. Dated J? U I By; JOHN SWEETEN, CLERK By eputy Clerk • ra.. . 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. 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 personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100 h 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. (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 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. .:::#:**:***..*•:.�*�::s:**.*«***:�s*s*ss«**«s«*s*sss***sss.:***�***«****«:*:****.::.***** RE: Claim By Reserved for Clerk's filing stamp An � �8 6r,'ue.l(o & 3a Po r1 W-7 %STa ) RECEIVED Against the County of Contra Costh or ) APR 19 2001 District) (Fill in name) ) CLERK BOARD OF CONTRA COSTA 00.SOBS The undersigner' -t,;+mant 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 damage or injury occur? (Give exact date and hour) Wednesday, March 13, 2001 2. Where did the damage or injury occur? (Include city and county) 98 Crivello Avenue, Bay Point, CA 94565 on the easement. 3. How did the damage or injury occur? (Give full details;use extra paper if required) We contact Ms. Lucy Owens, regarding purchasing the easement, but did not recieve a conformations. Which was done by returning the application that was fax to me. .-. ., .y' .. , �... _;� F<• ,. l ��%i2ii"`ri:i�iui:`�'i�'iiil Uf;)':�.«': W--hat particular act or omission on the part of county or district officers, servants, or employees caused the f' injury or damage? !• By not adhering to our request to purchase the easement: S. What are the names of county or district officers, servants, or employees causing the damage or injury? The Public Works of Contra Costa County Ms. Lucy Owns 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) I was told to vacate the' premise, which is the only access' to my carport, gargar and property, 98 Crivello Avenue, Bay Point CA. 94565 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) At the cost of $10,000.00 over a four year period. $2,5.00:00, per year, :which comes .to $7.00 a day plus a meal.. 8. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE AMOUNT Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) 'A even nU (.J �► �- (Claimant's Signature) u 11V-e. (Address) Nome Cc/2X-) ys8 413 r� Telephone No. )Telephone No. WC;de- ; (siy) 879-3,) 3 o NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defra-A,presents 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 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(S 1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars(S 10,000),or by both such imprisonment and fine. • r , p March 26,2001 TO: Board of Supervisors of Contra Costa County TO WHO IT MAY CONCERN: I am writing to you concerning the easement that basically sits next to our property 98 Crivello Ave.,Bay Point,CA 94565. The easement is the only way my husband and I can drive on to our carport, garage and have access to our property. Officer Tim Corona advised me verbally,Edwin White,Wednesday,March 13,2001 to remove my personal property off the easement by Monday,March 18,2001, which was impossible,because of the short notice. Office Tim Corona demeanor, when he approached me was threading and his gestures insinuated that he would inflict harm or punishment to me because of the uses of the easement. Initially,I fenced the area in August 2000,after making numerous complains to the police about the vagabonds sleeping on the easement,prostitution,dirty needles dirty condom and being used for drug dealers laundering point and drug users conducting their business. Mrs.White and I thought since the property next door was being purchased, most of the negative activity would be eliminated. No! It continued the drug dealers are still dealing drugs next door. I don't want my family to get injured by encountering debris from next door. Mrs. White and I have been maintaining the abandon easement for four years; which requires the exertion of time and energy to clean the habitual trash that is blown onto the easement and the debris thrown onto the easement by the public. Because we have been maintaining the easement for four years, we are asking to be consider under the squatter's law(adverse possession),be allowed to purchased it or receive restitution of$10,000.00 for maintaining the easement,keeping it clean,and for stopping the negative traffic for four years. Sincerely Mr.Mrs.Edwin White q(6 e -We-ub AL)e b OLL v n� S CA ���� �b g-q 3`-<p October 15, 1997 To the Contra Costa County Shrift Department From one resident of Bay Point We are constantly being overwhelmed with smoke from a near-by resident , turning his car in circle, which are called donuts, in front of Crivello Avenue and Siino West . We are also bombarded with the drug dealing from the two vacant houses across the street and the house adjacent from our. There's nothing can we do, but stay by and let a drug business continue near us; which endangers our family freedom in fear of being harassed by the drug sellers and drug buyers . The neighbors have been complaining about the vacant houses being use for drug activities, but no one have heard their concerns and most of them are too afraid to tell . The only way we have been able to keep drug dealing and other problems from happening, on 'the easement, is to enclose the easement with cars and trucks of our own and our friends, so that it will discourages the drug customers from using the dead-end-street as a means of stopping to get and use their drugs . Another reason for putting the vehicles on the easement, is that we have been finding old dirty needle and condoms in our yard and on the easement . My two year old and the children I care for, on the weekends, have also found several dirty needles and condoms brought.- from the neighthoods ' drugs and prostitution dealing on our property and on the easement way. The vehicles are also kept their f keep the chilc:.ren from getting hit from the car(s) donuting on street . We really don't want any thing to happen to our child or the others we care for, but we don't know how to handle this problem no other way. We are doing what we think is the best way to handle drugs and donuts situation. If there's away that the county can excavated the and illegal activity, we would appreciate it being implement. Sincerely ` ------ ---nnAnhna- Whit e-- ---- - - ------ -------- _- -i-�---- 7sa -� �. � �/,. .'.1 t _ •_. I r_.. S•. .. .... • 1 � t � .. �. L. - .. . � _ ... - - !. .. .. 1. _ .. .. � _ L _ � � '. � - � .. ... t /: � .. _ .. _ .. .. _ !. � � :. .J J � , . � _. � .. _ w. '�. .... .. _.. � .� .. .. 1 � r .. � - .. i ...t 1' ..�1 ... .... � • - ..v. .. ' 3 , CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALHORNIA BOARD ACTIO May 22, 2001 Claim Against the County, or District Governed by 1 the Board of Supervisors, Routing Endorsements, ► NOTICE TO CLAIMANT and Board Action. All Section references are to 1 The copy of this document mailed to you is your California Government Codes. ��� 11W�, notice of the action taken on your claim by the �WJ Board of Supervisors. (Paragraph IV below), given APR 2 0 2001 pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". COUNTY COUNSEL AMOUNT: TBA MARTINEZ CALIF. CLAIMANT: Maria P. Abrahamer ATTORNEY: Andrew.J. McCall DATE RECEIVED: April 19, 2001 ADDRESS: 1299 Newell Hill Pl #300 BY DELIVERY TO CLERK ON: April 19, 2001 Walnut Creek, CA 94596 BY MAIL POSTMARKED: April 18, 2001 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWE Clerk Dated: April 20, 2001 By: Deputy H. FROM: County Counsel TO: Clerk of the Board of Supervisors ( "This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �-o, 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). 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 mi utes fo this date. Dated: �a JOHN SWEETEN Clerk, By eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage,fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claiman s shown above. r� Dated• a r' By: JOHN SWEETEN, CLERK By 1 puty Clerk r V 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. cairn to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIIVIANT A. 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 before December 31, 1987, must be presented not later than the 100`" 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 anv other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2. ) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,651 Pine Street.Martinez. CA 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. RE: Claim by ) Reserved for Clerk's Filing Stamp MARIA P. ABRAHAMER RECEIVED Against the County of Contra Costa APR 1 9 2001 or CLERK B0;',AD OF SUPERVISORS CONTRA COSTA CO. District) (Fill in Mame) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sum of S TBAand in support of this claim represents as follows: 1. When did the damage or injury occur? !Give exact Date and Hour) 10/24/00 -------------------------------------------------------------------------------------- :. Where did the damage or injury occur? (Inciude City and Counrc) Sidewalk on south side of Clayton Road, just west of Ellis Street, City_ of-Concord, County of Contra Costa. -- --- ------------------------------------------------------------------- - 3. How did the damage or injury occur? (Give full details:use ex=paper if required i As Mrs. Abrahamer was .walking northeast on the sidewalk on .the south side of Clayton Road between Adelaide Street and Ellis Street, she tripped over one of the metal handle-shaped -fixtures set in the sidewalk':and fell on her left hand. See _attached _photos of fixtures. 4. What particular act or omission on the part of county or district officers, sen-ants, or employees caused the injury or damage? The County may own, or have placed, or authorized placement of, or failed to prevent placement of the fixtures. (Over) S. What are the names of county or district officers,swrants,or employees causing the damage or injury? Unknown at this time. 6. What dama-es or injuries do you claim resulted" (Give fnli extent of injuria or damages claimed. Attach two estimates for auto damage.) Multiple- fractures 'of the left hand and fingers. . ------------------------------------ 7. was the above claimed amount computed" (include the estimated amount of any prospective injure•or damage.) Claimed amount is currently undetermined as the injuries have not been resolved. ------------------------------------------------------------------------------------.- S. Names and addresses of witnesses,doctors. and hospitals. -. Mt. . Diablo Medical ,Center (ER) ,_.- 2540....East -Street,. Concord, CA 94520 Diablo .Therapy Center, 2525 Stanwell Drive, Concord, CA 94520 Dr. Torsten Jacobsen, 2485 High School Ave. #214 , Concord",. CA 94520 ---- - - - - - Dr_ Teresa E. Rudlowski, 2485High-_ - -- - - - School Ave. #110 , Concord, CA 94520 9. List the expenditures you made on account of this accident or injury: DATE I'fEy1 .010UNT f •!.Unknown at this time. Goy. Code Sec.910.. provides: The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney (y rY Andrew .J. McCall ! `, O'Brien & Sullivan lflait;re�_ 1299 Newell Hill Place #300 Walnut Creek, CA 94596 Andrew J. McCall Attorney -fol-aimant Telephone No. 925 935-8800 Telephone No. NOTICE Section `2 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 ( S1.000 ), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars (S10,000 ), or by both such imprisonment and fine. 4 2 f t 4 y .� J � / f �p•yn ij '. ';��-t e a}. •ti fir{�.���� r+. t� fF'.>'•F AVG oz - t •wt"' F� 00 41 � r _ -' .��•. _ � .ice '=,� _ �_9 r f �� ,err r,• Jt dt' J � ';r`' .vim g'-�,"�.r3yfer. :•,T,4l.��il.�r �F:;614�.S�a'�:[..3E$..N�,. P7. 77 samsolaug Pp/m-v HUDOW Y MarPud `smOX XlrW X.ran llra asmId`suoilsanb Xur aAuq noXjl •PaptAojd adolanua oLp ui Xdoa paduiuls E um4az aseald �aur>✓>l�>gd�r y�l`�uarla�Cru�o�l�rlaq uo ut iLuclns um I rlanlM,/�unoo visoD v a;uo j psuzv2V ugvID jo Xdoo auo pur lL'ulSuo aril asolaua I :IS ROCI 00/17Z/OI :juapgaul;o alRG aatuvgv.igV•d uple l :ag £99t,6 dD `zauTWW POAS quid 199 2triplmg uoil,0.4srunupd flunoJ`90i uzood s.zosiAlOdnS jo pmog ogjjo lralD IOOZ`8l ludd ILb8-5£6(SZ6) 3NOHd3"13l XVI 'I"IVDJ V'f M3MGNV 0088-5£6(SZ6) KVAI"I"IAS'l GdVMQ3 :1NOHdTIa.L lulsfI.0 SINN13O OZZ9-969t6 VIM'dOi11V7 `�13321J .LfIN IVM 3OVld IIIH 113M3N 66ZL' 00£ 311ns NVAI'I'IfIS ?g NHI-d9,0 IO S3O1JI0 MVI m � z y Cs1 � 9 mN CY, 0 c � � m N � 0 N 0 N N O cls � � p rr"•'* ��,,, N N i ✓' rola Al. a�lfj 01Ap �L t k:,4 C CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTIO tIt May 22, 2001 Claim Against the County, or District Governed by 1 the Board of Supervisors, Routing Endorsements, 1 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 pursuant to Government Code Section 913 and APR 2 0 2001 915.4. Please note all "Warnings". COUNTY COUNSE AMOUNT: 631.52 MARTINEZ CALIF. CLAIMANT: Ethel Silverberg McClintock ATTORNEY: None DATE RECEIVED: April 20, 2001 ADDRESS: 727 40th St. BY DELIVERY TO CLERK ON: Aptl 20, 2001 Richmond, CA 94805 BY MAIL POSTMARKED: April 19, 2001 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN S EN, Cle k Dated: April 20, 2001 By: Deputy 11. FROM County Counsel TO: Clerk of the Board of Supervisors (This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 91 1.3). ( ) Other: Dated: ���� �r By: "' Deputy County Counsel III. FROINL Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 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 a ered in its rn utes for this date. Dated JOHN SWEETEN Clerk, By ", ty Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant addresse to the cl iman as shown above. Dated: By; JOHN SWEL'TEN, CLERK By y Clerk • 1 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 un'derstand 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 CIaims Act. Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY c _ INSTRUCTIONS TO CLAIMANT A. 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 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. (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 claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp Against the County of Contra Costa or ) District) (Fill in name) ) The undersigned plaimani hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 7 <?. and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur?(Include city and county) • A / [Cly /�� �-►� �� �c���,f�'� G��� L� �i i��f� 3. How did the damage or injury occur?(Give full details; use extra paper if require k' !,^ �, y ={ ,�., raj►-� /��y 4. What particular act or omission on the part of county or district officers, servants, or employees caused the ` injury or damage? ' de, iC A G S6 S fTle 1,,4- c ,4 t hl (04 S. What are the names of county or district officers, servants, or employees causing the damage or injury? LC-4 G,r 6. What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) .T- ' l�� * 69,5"-2- / 7. 9,5 .2- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) � 111 8. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE TIIyiE AMOUNT ) Gov. Code Sec. 910.2 provides "The claim must be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) �74,d) J/he (Claimant's Signature) (Address) ) Telephone No. )Telephone No. **:s**************s**#s�*ss*�**•*****�s**s***s**�*•******s**s�****�s*o******.**********�** NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents 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 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(S 1,000), or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. 1.{1 } } AE t \ c o � N � .ct N � d S m Q r Q O G m lv . •, 1 f . l i •ti h1 r