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HomeMy WebLinkAboutMINUTES - 03012005 - C22 i CLAIM BOARD OF SUPER.VISORS OF CONTRA COSTA COUNTY BCH 0l, 2Q05 BOARD ACTION fit, Maim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), give Pursuant to Government Code section 913 and 71 915.4. Please note all"Warnings". y 5, AMOUNT: $323.39 1 J A Ng CLAIMANT: SHELLY ZYCADLO COUNTY c,,,,, .f w A41A RIS 6' t' ,:l. . ATTORNEY. UNKNowN DATE RECEIVED: ,JANUARY 18, 2005 L ERY TO CLERK ON:JANUARY 18, 2005--- ADDRESS,. 6 23 33rd STREET, BY DE TV RICHMOND, CA 94804 ,JANUARY 14 2005 BY MAIL POSTMARKED: ' FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEJET ; ClerkClerk Dated: _...�...._ 1AlU �Y 189 zoos By: Deputy GIs II. FkOM: County Counsel:. = TO: Clerk of the' Board of Su rvi ors (w)'I�h�is-claim complies substantially with Sections 910 and 910.2. This Claim FAILS to comply substantial) with sections 910 and 910.2, and we are so notifying claimant. The { ) py Y 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: Deputy Count CourB 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: 11XV44 40�' "��70�SWEETEi'�T CLEC B Deputy Clerk y p Y WARNING(Gov. code ection 913) ,1 - 1'______ L1__ .�... .. �G.in r+r►fin�s ZIT�C� marctln lv cc.rvP.d or denosi JAM-10-2055 14:41 CCC RISK MANAGMENT 925 335 1421 P.02/03 t BOARD of SUPERVISORS OF CONTRA L;UbTA 1:v UA s It INSTRUCTIONS TO CLANCAM a ' A. A. claim relating to a cause of action for death or for injury to person or to personal property or owing crops shall be presented not later than six months ager 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 fine Street,Martinez,CA945 5 3. 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 t= -one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent clan' ns,Penal Cade Sec. 72 at the end of this form. no a ass amNow a■anus aUna■massnoaaa■ass■saasannas■■aaaagoama■•e;s a.■taa■:eaamen names■e RE: Claim.By: Reserved for Clerk's filing stamp } SHELLY ZYOADLO } 4k"wL .Against the County of Contra Costa or } `U JAN 1 '8 District) CL�Rk'e011 (Fill in the name) 'o��o o s } OR*r RVISORS The undersigned claimant hereby mares claim against the County of Contra Costa or the above-named district in the sung.of$ 323-39 and in support of this claim represents as follows: 1. Whet did the u '"damage or in' occur? (Give exact date� � and hour) SATURDAY JANUARY 81 2005 at 12:34pm 2. There did the damage or injury occur? {Include cit end county) y} EL SOBRANTE, CONTRA COSTA COUNTY ,A 1'FIAN WAY, NEAREST CROSS STREET RANCHO 3. How did the damage or injury occur? (Give f�� details,use extra paper�f required) SEE red) SEE ATTACHMENT FOR DETAILS 4. "'what particular act or omission on the art of count or district P y officers, servants, or employees caused the injury or damage? DUE TO PERVIOUS MAINTAINS ON TH ROAD, IT LEFT A PATCH THAT TURNED INTO A POT HOLE 5 What are the names of county or district officers servants or employees damage injury? CONTRA Go � - � P ogees causing�.e g or injury. STA COUNTY JPN4610-2005 14:41 CCC R I aK Mf-NHU1'JtJ-4 I t " ulte{�`� (Give fi�I extent of injuries► or damages t injuries do your claim res �'. That damage or � . d. Attach two estimates for auto damage.) c�a:�e . SEE ATTACHMENT � - 7. how was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) SEE ATTAHCMENT 'tnesses doctors., and hospitals: g. Names and addresses of Witnesses, SANDIE PARKER 4323 WESLEY' WAY, EL SOBRANTE CA 94803 DEBBY ZYGADLO 3838- MILTON DRIVE APT 1! EL SOBRANTE CA 94803 9. List the expenditur you ou made on account of this accident or injury: DATE T AMORT NONE �wr�r �■ilr•isslt�rlrls•lisMass now �'��M�#lril!■t�1i##S■i•!#!»•#M#Mi#iMR#=!M'i!R■1i■ ■i#!w!t•M##i Code Sec,, 9 10.2 provides "The cl ►�.shall be } F�rov, � P signed by} the clamant or by some person on his }behalf." NOTICESJ0: o e..yj Name and address of Attorney �4} a"i' 4is Si nature) } (Address) Telephone No, L Telephone No. hone� p .{ ��■sisr�lssssl�ssssle• �5 XaIononof11A11XV111131mass so lage■nalnosgas1111Iant PUBLIC RECORDS NOTICE: Please b � or an e advised that this claim form claim filed with the County under the Tort Maims Act, is subject to �' public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthennore, any attachments, addendurns, or supplements attached to the claim form., including medical records, are also subject to public disclosure. # IKi>Xt•iiltii!•#!!ii s■Xmas M#anago#illi#i*#i41fiM#lsvanxn###pages nassasses###man■r!#■t!■■#wl NOTICE Vection 72 of the Venal Cade provides: Every person who, with intent to defraud,presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorised to allow or pay the same if genuine, any false or Fraudulent cairn, bili, account voucher, or writing, is punishable either by imprisonment in the County,fail 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. TCTPL P.03 • 3. I WAS DRIVING 30 MPH ON APPIAN WAY IN THE RAIN AND I DID NOT SEE THE POT HOLE. I HIT IT SO HARD MY WINDSHIELD WIPERS TURNED OFF. IT BROKE MY VILE STEM ON MY TIRE AND I HIT MY REM ON THE POT HOLE SO HARD IT BENT MY RIM. I HAD TO REPLACE THE TIRE AND NOW I HAVE TO BUY NEW RIMS. THE TIRE COMPANY RECOMMEND TO REPLACE THE RIM. I'M SEND YOU INVOICES ON THE DAMAGE. (SEE ATTACHMENTS 6. THE DAMAGE WAS A FLAT TIRE THAT I HAD TO REPLACE THE WHOLE TIRE AND A BENT RIM. I HAD TO REPLACE ALL MY TIRE SO THEY MATCHED. THE TIRE COMPANY SAID IT IS NOT GOOD TO HAVE TIRE THAT DON'T MATCH. I ONLY HAVE ONE INVOICE BECAUSE I HAD TO GET IT FIXED RIGHT AWAY. 7. I JUST WANT TO BE REIMBURSED FOR THE ONE TIRE THAT HAS DAMAGE. I CALCULATED HOW MUCH I PAID FOR THE TIRES $394.54 AND THE RIM$899.00 THAN DIVIDED IT BY FOUR.TO SEE HOW MUCH I'M OUT. 394.54 + 899.00 — 1293.54 % 4= 323.39 SHELLY ZY . ADLO 62333 R' STREET RICHMOND, CA 94804 394o54+ 510-232-5453 8990 + 1p293984 1 Y293*54 4 0 323*385+ • «0• • w 01/\10/2005 06:07pm *** INVOICE *** page: 1/1 Larry's Tire Express 31 Pitt Way El Sobrante, CA 94803 510-222-1914 F Invoice #: 0464 Bill To: Ship To: Unit #: Shelly zygadlo Vehicle: 623 33rd st richmond, CA 94804 License: Home: 5102325453 Mileage: Out: 32500 VIN #: PO #• b,..5...r t .. ......:',•:,.::}:•.,:{<.::,r,.:,,.v{.;r••,ik':.•:•v..:,r.,3 vr•}:;<:�::.::::w:..r: }} ....,,rv. ,.., .{.>.....•.. Y>r Y„ r.>r,:..r:.,t.,..F,arr, .. ....,,. ,,,<{.,...., .,:,. r.:...... ,,..rY.,,.. a r p7.... r. ,r ..., a....,v,•v..�y {,...,•... ;..,ry„•:::.•,S• ..::! {5...:h;i } ,#.r}.,..........Y. , a r ,....2..r.,... 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'•:1•.r..k..r f,..n R a�• r3 i::3:;. {•,,.f .t....! lilir! �.,k,.i 1f.,-,,f ..'i t.:.,, JJn � tA,f". k....rr i,1.3 11{.i'•,k la^,'.i .., • 'r �":"{ .M��a'ir°i+Ft�1•.l,.i „f,.a3la+, Comments: If//c::- 'rr "4r.'Z i Cash: CC Number: Auth Code: ' 0.00 check: 0.00 Parts: 365.00 Credit Card: 394.54 On Acct: 0.00 Labor: 0.00 Subtotal: 365.00 Amount Tendered: $394.54 Sales ''Tax: 29.54 } Total: - $394,54 Change: $0.00 Total: $394.54 T ',•J ty�, yMH' . , rYYWyI,•'}• �,. �. N � �,o pts• ,, Y N © * oho T v�•I� ©•Z+��r; ?, � 0 d^d� tea)'�.• � d�N O �y ��d p G�•y,eL•gyp, ,a �p"p,°v .L4 �a�s •�tt1 to p �` �Y �a tS�4 dd•O �s o o . o� V G© v - �d3.- .. 100 o d ~ O O O d c4 Or G * 00 ..,. - r �1 'Q .W` � � s..� � ,y�� ' ,. O ^Ory G�'�O•� � ���r��,��wA� Y` wL t �ij` {w1 7v • •�G V/'Y W 4x� 00 ' k S3 tU 05 1p 000 d d �N•d } . UQ N y Cs•o •' Rt �ccs Gip ON �' i V 0) d)OS Z3 � �' ',t,t, •► I.- ,,,- 0)t�ply .• s07 � � ,{��`ii"�� � ^; ..,r.a►. ',*+�±'° t`�, O ,. �Z}°.✓�6 �G�Y+ 'I"G G JL4�Oc4 s os ul ^ � ,x,.+, � rte, na M� � ✓'�to G�"�" � �,.,�;��i� w '~�, ,•,. rU k �..- �� �t'• 4 t3)�G tom„) t',O i'7�'UG c� to OS 12 tT . Q y cS r <500001 ...•£G 00 Asow t� 'i Q Cr co co) ui �.,,,y ' ►4.. ^� fir. aM CD<<. Un �,,�,,. �' .• r 0 Ca Ce) LO Er _---;, O CD ---�''" uj ...••- ,a CSG � � �' dy ��.� to tx ,r tae �a � CLAIM 2 OZOO#e �b BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION. MARCH 01 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), givc r v. u,.. Pursuant to Government Code Section 913 and r 915.4. Please note all "Warnings". AMOUNT: $10,241.00 COUNTY MARTINEZ CALF. CLAIMANT: JUAN AND DONNA ECHRR IA ATTORNEY: UNKNOWN DATE RECEIVED: JANUARY 19, 2005 ADDRESS: 869 BANCROFT. ROAD BY DELIVERY TO CLERK ON: JANUARY 19, 2005 WALNUT CREEK, CA 94598 RECEIVED THROUGH BY MAIL POSTMARKED: INTER-OFFICE MAIL FROM PENNY BAILEY FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN, Clerk Dated: JANUARY 19, 2005 By: Deputy � p y II. FROM: County Counsel,. .- TO: Clerk of the Board of SuperAors (0oolhis 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: By: Deputy County y 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. OARD 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. 01 0g, Deputy ClerkDated• dJOHN SWEETEN, CLERK, By WARNING(Gov. code sec on 913) \.1 f�1 A A� �A /\A MF A S N A\I A A M T 1/�M A �I A 1� M���s w w u��� ���. I�l YA I1 rA�M A T M/�\NA ��A A A�I� ���A �A A��A A ��f/1 A ��A M A A i.�f1■■fi t A w anti..w A w u �i w u���� ^JAN-�,,.-3-2005 13:44 FROM: Tl:9335142�r-)�� Bow OF surERvIsoxs of corrr�cosTa COUNTY _ INSTRUCTIONS TO CLAIMANT 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 gelating 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.) Be 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 44553. 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 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 -V �j RECLIVED Against the County of Contra Costa or ) FANJ 99 /0� District) CLERK BOARD OF SUPE 60 r.ONTRA C0fiTA f'0: (Fill in the name) } l Theundersignedclaimant hereby makesclaim against the.County of Contra Costa or the above-named district in the sum of$ ped_in support of this claim represents as follows: 1. When did.the damage or injury occur? (Give exact date and hour) ZN& 14o(4 0 u 2. Where did the damage or injury occur? (Include city and county) okKL �� co s�� 60 U �►-� 3. How did the damn e or in' occur? (Give full details• use extra a er if required) g Jam' � P P 1 S �(,�'!M� CON 0 cir� Tnp 4. What p 'culaz actor onussion on the part of county or district officers, servants, or employees caused the injury or damage? Lu af,. +b S"V)� `P D Ai n T S C-C- I%A-F 5 What are the names of county or district officers, servants,or employees causing the damage or injury? JRN-13-2005 13:44 FROM: TO:93351421 P.3/3 rte'' 6. Whaf Barna a or injuxies do your claim resulted? (Give. full extent ofinjuries or damages cla ned, Attach twvo estimates for auto damage.) � �3 71 t� �,u DC S/0(-b firs h�- � � PSS _111.0 - � ' tzar t, r1Z6*TAP1 cr tt�T"1..r, - , ID e estunated owot of an 7. How was.:.the amount claimed,. above compute,.. ..C 10�+ M (9(ctMdl�e y l -- ros echve in ur or Barra e. _ _ _ p P Y g 1 -ft SLC �A'C..V f' 1, E _ G CC: f ��ft..; Q th 8. Names and addresses of witnesses, doctors,and hospitals: J ks 0 r V Aw S(4L od, s }. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT Ou P U - - fTrij " ..,....E..a.■.a■a'■■■a.•.a■■an■a ..s ........ ..■. .■■•.....■l .Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimanf or by some person,on his behalf." •..,,,, SEND NOTICES TO: (Attorney) Name and address of Attorney ) atrnat s blignaTur • "P7r (Address) U - or -4 C = air . Telephone NoTelephone 77 p ) lephone No ■■■aaaa851a2maIs•a■■aaago 0 ■■r•■■■'No■■■ and loops als■a■■Oman■a■0annonsonseea■-Room Ronson■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 6504 et seq.) Fuarthennore, any attachments,addendums, or supplements attaclled to the claim form,including medical records, are also subject to public disclosure. soon ROMEO■t••■Eggs■■■vanssr`a■■■at•■■■soon�01■■amass swung a■•■•■a■aa■s:•_■■-r■a■owns■-■■■■i NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud,presents for allowance or for payment to airy 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 ($13000.00)3 or.by both such imprisomnent and fine, or by imprisonment m" the state prison, by a fine of not exceeding ten fihousand dollars ($10,000),or by both such imprisonment and fine. 4 a CLAIM BOARD OF SUPERVISOR.S OF CONTRA, COSTA COUNTY BOARD ACTION: LARCH 01 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), give ,R f Pursuant to Government Code Section 913 and �x 3 4' y, b p j � 915.4. Please note all"warnings". JAN $ 'I) AMOUNT - AMOUNT: $39508-35 CCUNTY G0 ,,1 <A MARTiNEZ ��Li F, CLAIMANT: HARTFORD INSURANCE A/S/O NASSER BARABI BY: ROBIN A. BROWN ATTORNEY: UNKNOWN DATE RECEIVER: JANUARY 19_, 2005 ADDRESS, BY DELIVERY TO CLERK.ON:.JANUARY 19, 2005 100 ENTERPRISE DRIVE, ROCKAWAY, N.J. 07866 RECEIVED THROUGH BY MAIL POSTMARKED: INTER-OFFICE MAIL FROM PINY BAILEY FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SwEETE C Dated: JANUARY 19, 2005 By: Deputy �..�rm .�+��..��i..ni�.�rrr�w�.r r�n rri w•.r.r�.irr M' II. MOM: County Counsel:. TO: Clerk of the Board of Superv' ors ( This 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 4- 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. CARD 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 0 Z � De ut Jerk JOS SWEETEN, CLEC, By p y C WARNING(Gov. code section 913) • r/t --_1L_ r... ... ;1... .-��+s+^aitn rsr.#lnaa 7tr�ic nPrcnnally served or denosi CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MARCH- O1 2005 Claim Against the County, or District Governed'by TO CLAIMANT the Board of Supervisors, Routing Endorsements, NOTICE - - and Board Action. All Section references are to The copy of this document mailed to you is you California Government Codes. notice of the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), gi., Pursuant to Government Code Section 913 and 915.4. Please note all"warnings". AMOUNT: $3,508.35 CLAIMANT: HARTFORD INSURANCE A/S/O NASSER BARABI BY: ROBIN A. BROWN ATTORNEY: UNKNOWN DATE RECEIVED: JANUARY 19 2005 BY DELIVERY TO CLERK.ON:JANUARY 19, 2005ADDRESS: 100 ENTERPRISE DRIVE, RECEIVED THROUGH ROCKAWAY, N.J. 07866 INTER-,OFFICE MALI BY MAIL POSTMARKED: FROM PENNY BAILED FROM: Clerk of the Board of Supervisors' TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETE C JANUARY 19, 2005 By: D 'u Dated: Ilrlrl ep .ty d II. tk 0 M_: County Counsel. TO: Clerk of the' Board of Super-vors C ) This claim complies substantially with Sections 910 and 910.29 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: By: Deputy County Coy 111. 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, O Other, I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOHN SWEETEN, CLERK, By J Deputy Clerk WARNING(Gov. code section 913) .4 ^ At - -1-A-- 41-!- ­4:,,mv-tr#%cw v%darannallu ciarved or den( r This warning* does not apply to claims which are not subject to the California Tort Claims Act-such as actions in in 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'daim, A K 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 TortC1Qims Act. r ' t 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 Cotta does not waive any of its rights under California Tort Claims Act nor does it waive rights under the. statutes of limitations applicably to actions not subject to the California Tort' Claims Act. 1 1 62-2905 09:02 CCC R I SK MRNAGNENT BOARD OF SU'PExvv.**v" Y zfr _67J 0 5, 3 3%25 14 2 1 INSTRUCTfONS TO CLQdMAN T. P.02 A. A clairn relating to a czjse of action for death or for injury to person or to personal properry or growing crops shall be presented not later than six months after the accrual of the cause of C� action. A claim relating to any other cause of action shall be preseiate:d got late:than one yxttar after the accrual of the cause of action.. (Gov. Code § 911.2.) B. Clzdras must be filed with the Clerk of the Board of Supervisors at its office in Room 106, C ount�r Administmtion 13 uilding, 65)I Nue Street, Mardnez, CA 945 5 3. C. If claim is against a ddstrict governed by the Board of Supervisors, rather than the County:, the name of the District should be Med in. D. If the clairn is agai= more than one public entity, separate claim's ra-Ust be faled against ea0h public entirv. E. Fraud. See ptnalvr for fraudulent claims,Penal Code Sec. 72 at the end of this form. XX%M on a Sunman a*Imnows aws an kummasy we Mann Mary MANSMUMPEN Mn8 MAU ItIft 0 RE Claim 8y: Reserved for Clerk's filing stamp day-4- �-rrG Els no RECEI - In ST .A%W' the Co ry of Contra Costa or JAN 19 C DistrictLER 183 A RD OF ) —1 r'OA/7-p,4 (Fill -in the name) O�R ror ORS I e'undersigned claimant hereb) mMakak S claim against the County of Contra Costa or the above-named Th dict in the sum of S and in support of this claim represents as Follows. I. When did the damage or miury occur? (Give exact date.aad hour) V­^ C1 2. Where did the damage or injury occur? (Include city and couut �r�iM v) L How did the age or in' jury occ ? (Give fU de-mils; use extraPaper if rpquired) 01 L I ks. 6'.J% k 4. 1 particular act or omission on the part of c*uwy or district officers, servants, or employees caused the 'injury or damage9, 2ZO-S Rord Vt(­k$ 113q31q 5 What are the narnes of'county or district officers, servants, or employees causina the Jae or injury? L VV4 7f7:PT Co()7/7-T/To 09:02 CCC R I SK 01RNAGMENT 925 :3435 1421 P.c-1 (Give fuE extent of injuries or darnaps 6. What damage or inju-tits do youx claim resulted? Mi W? I chimed. Attach two estimates for auto age-) � moo• ed above co' uted? (Include elle esthated amwaint of any 7. How was the ajmc)unt claimed MP prospecilve m3uxY or damage.) 8. Names and addresses of witnesses, doctors)and hospiws: IL V- 9. List the expeaditures you made-on account of this accident or MJury: " a DATE TIME -AaMOLTNT a as Run 3 0 1 Run up, Mal m Gov. Code Sec. 910.2 provides"The cls shall be signed by the claimant or by some person on bis.0 713 00 SEND NOTICES TO (ATtorr)ev) Name and address of Attomey kAA (Claimant's Signature) c 11AL- A AiL Q �� op, (Address) b-� CJ cy Telephone No. Telephone No. 0 am RENVANKM Mann g a a a M a■a a x a■a 9 a a u Dumb manummumuff as 14000 Ramona at PUBLIC MCO"S NOTICE: Pie�se be advisedthat this ..Iaixn form: or any claire filed with the County under the Tort Claims Act, is subject to F ublic disclosure under the California Public Records Act (Gov- Code., §§ 6500 et seq.) Furth=more, ariy attachments.addendums.. or supplements-,attached to the claim form, including medical records, are,also SubjecTLo public disclosure. a man n a M ptax an manage Mmunala mmensumam 0 ON ban 8 IN a,1111hrm naval NOTICE: Secrion 72 of theo Penal Code provides: Every person%rho, with intent to defraud,presents for allowance or for payment to any mte.board or of:Fjwr- or to any county, city-, or district board or officer, authorized to allow or pay die same if genuine, any false or fraudulent claim, bli.11, 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 tan thousand dollars ($10,000). or by bot-b such imprisonment and fine, TDTAL nwzzTnnn r.% N7 W T "T.4 0T PAINS /'YT/TA +1� ,V K �:, 2 1vt Q CCC P I SK h ANAGMENT County Administrator Contra' 925 335 1 .21 P.01 Risk Management t3lvi5icth Costa 2530 Arnold Drive,Suite 14u . ber (925)335-,424 t; ttinaA.Q+Cl±fomi•a 94,,53 CountvFax rjur, A� •it •.. r FAXMESSAGE ji DA TE: i - ` _ Fac. � APem-- + klcA FaXI-4 (925) 335-1421 Phone' Claimant- SUBJECT: Date of Loss%- Number e 'nE this Covert aae: o�pay, s ir�c�u�� � p Messac,e: l ltiF 1 PLEASE-NOTE: 171e it f0r777c,ria77 C.Vnt0h7ed i77 this fcrc-sim le message moi• be condentiol andelor leaalIv grit}ile�ed rr7�fnr�37 riv77 i73r�t7CI CY or7l. 'rfor I.I7e Z�,ti•e Of Me 11'IG'API*du0l Or er7tin. r atned cibove, If rhe reader of chis mes•�aL��� is not the iairerzclec{rec•rpivu, vo7� erre hereby 17oryied thot rhe copying, djSsc�n7I'n lrlorj or divrribzttiorj of corr�dewlal infotrlr ai o�? is sn-ic•rIyp7-(;hibirecI. I YOU hGVe 1701 j-eceived ull cif the pages in this message.please comact Me or the Crb0):e PhOl7e number, �`hc7t7l���vu a� Tarc 1 IrV j 7f,e eT Qtl(lr,rte T;Til • Y 11/05/2d004HE i Henry Fockler HiRTFORD 274 Crestview Ave Martinez, CA 94553 '` Our Account No. SUB889071 Claim Number: YJS AC 15284 Cour Insured: Rose & Nasser Barabi Dastmalchi Location of Loss: Near Alamo, CA Date of Loss. 09/09/2004 ' Amount of Loss: $39508.97 Bear Henry Fockler, The Hartford insures Rose & Nasser Barabi Dastm.alchi with whom you were involved in an auto accident on 09/09/2004 in Near Alamo, CA. As a result of the accident, we have paid our insured $3,508.97 for damages to their auto. Our evaluation of the circumstances I of this.accident indicates that your auto was operated negligently and under the terms of our policy we are making claim against you for reimbursement for the amount paid. You have a right to dispute any or all of this debt. If you do not dispute this debt within 30 days of receiving this letter, The Hartford will assume that this debt is valid. ,You have a right to receive a verification of the debt, a copy of the repair estimate, a copy of the check. that The Hartford paid to its insured, or to the repairer of the auto and any or all other documents which verifies the existence of the debt. Please contact the undersigned as to how you plan to pay this debt without the necessity of legal action. Any information received by The Hartford from you will be used by The Hartford in the collection of this debt. If you are covered by insurance for this accident, please notify your insurance carrier at once. Please fill in the blanks below concerning your insurance information. If you do not have insurance for this accident, please contact the undersigned as soon as possible so that arrangements can be made to amicably settle this matter in a manner agreeable to all parties. Enclosed is a self-addressed envelope for your convenience in reply. Insurance Company . Policy Number , Company's address V. Agent AIU' �),y Address/Phone # r ,. Very y y ours truly '{= Garden State Central Recovery Office Robin Brown Rockaway 80 Corporate Center Hartford Casualty Insurance Company 100 Enterprise Drive P.O.Box 3000 973 607 5159 Ext. Rockaway,NJ 07866 robin.brown@thehartford.com Telephone 973 607 5000 Facsimile 973 607 5112 09/23/2004 AT 04:53 PM 0098212362 61346 THE HARTFORD WPLCSC CI 4200 PARK BL FMB # 244 OAKLAND, CA 94602 (800) 811-4832 FAX: (510)530-0270 ESTIMATE OF RECORD WRITTEN BY: ROBERT HARVICK 09/23/2004 04:47 PM ADJUSTER: ANDREW BRAND (800)811-4832 INSURED: NASSER BARABI CLAIM #0098212362 OWNER: NASSER BARABI POLICY #57PH 257615 ADDRESS: 4067 HAPPY VALLEY RD DATE OF LOSS: 09/09/2004 AT 08:35 AM LAFAYETTE, CA 94549 TYPE OF LOSS: COLLISION DAY: (925)286-3230 POINT OF IMPACT: 6. REAR EVENING: (925)284-7199 INSPECT PROFESSIONAL AUTOMOTIVE ENTERPRI REPAIR-SHOP LOCATION: 3331 MT.DIABLO BL LAFAYETTE, CA 94549 REPAIR PROFESSIONAL AUTOMOTIVE ENTERPRI BUSINESS: (925)283-2160 FACILITY: 3331 MT.DIABLO BL 5 DAYS TO REPAIR LAFAYETTE, CA 94549 LICENSE # 68-0054176 2002 BENZ. CLK430 8-4.3L-FI 2D. CNVT BROWN VIN: WDBLK70G52T107400 LIC: 4VQZ580 CA PROD DATE: ODOMETER: 31212 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS AUTO LEVEL CLIMATE CONTROL THEFT DETERRENT/ALARM STEERING WHEEL CONTROLS DUAL MIRRORS TRACTION CONTROL FOG LAMPS CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER PASSENGER SEAT POWER MIRRORS ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES ROLL BAR POSITRACTION LEATHER SEATS BUCKET SEATS ALUMINUM/ALLOY WHEELS. ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -------------------------------------------------------------------------------- 1 REAR BUMPER 2* RPR BUMPER COVER 3.2L, 4.3L W/AMG 1.0* 2.4 3 ADD I FOR CLEAR COAT 1.0 4 O/H BUMPER ASSY 2.0 5 TRUNK LID 6 REPL TRUNK LID CONVERTIBLE 1 348.00 2.5 2.1 7 OVERLAP MAJOR ADJ. PANEL -0.4 8 ADD FOR CLEAR COAT 0.3 9 ADD FOR UNDERSIDE(COMPLETE) 1.0 1 09/23/2004 AT 04:53 PM 0098212362 61346 ESTIMATE OF RECORD 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 10 REPL EMBLEM MERCEDES STAR 1 6.50 0.3 CONVERTIBLE 11 REPL NAMEPLATE CLK430 1 27.00 0.3 12 REPL EMBLEM GROMMET 3 1.20 0.3 13 CONVERTIBLE/SOFT TOP 14* RPR TOP COVER 3.0* 2.1 15 OVERLAP MINOR PANEL -0.2 16 ADD FOR CLEAR COAT 0.4 17* R&I MOLDING REAR 1.5* 18 QUARTER PANEL 19 BLND RT QUARTER PANEL 1.3 20 BLND LT QUARTER PANEL 1.3 21 BLND FUEL DOOR 0.2 22 R&I FUEL DOOR 0.3 23 R&I RT LOWER MOLDING 0.2 24 R&I LT LOWER MOLDING 0.2 25 R&I RT WINDOW MOLDING 0.4 26 R&I LT WINDOW MOLDING 0.4 27 REAR LAMPS 28 REPL RT TAIL LAMP ASSY 1 107.00 0.8 29 R&I LT TAIL LAMP ASSY 0.8 N 30 REPL, RT TAIL LAMP ASSY 1 74 .00 INCL. 31 REAR BODY 32* RPR REAR BODY PANEL 4.0* 1.5 33 OVERLAP MAJOR ADJ. PANEL -0.4 34 ADD FOR CLEAR COAT 0.2 35# FLEX ADDITIVE 1 8.00 36# **COPY OF ESTIMATE PROVIDED TO 1 37# VECHICLE OWNER** 1 ------------------------------------------------------------------------------- SUBTOTALS ==> 571.70 18.0 12.8 LINE 30 LITE HAS CRACK ON THE INNER STRUCTURE PARTS 571.70 BODY LABOR 18.0 HRS @$ 70.00/HR 1260.00 PAINT LABOR 12.8 HRS @$ 70.00/HR 896.00 PAINT SUPPLIES 350.00 ---------------------------------------------------- SUBTOTAL $ 3077.70 SALES TAX $ 921.70 @ 8.7500t 80.65 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 3158.35 ADJUSTMENTS: DEDUCTIBLE 500.00 2 09/23/2004 AT 04:53 PM 0098212362 61346 ESTIMATE OF RECORD 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 2658.35 THIS IS NOT AN AUTHORIZATION TO REPAIR.REPAIRS MUST BE AUTHORIZED BY VECHICLE OWNER.PRESENT THIS ESTIMATE TO REPAIR FACILITY OF YOUR CHOICE.NO SUPPLEMENTS WILL BE HONORED BY THE HARTFORD WITHOUT PRIOR APPROVAL,REINSPECTION AND COMPLETE INVOICES FOR THE ENTIRE REPAIR. FOR ALL REINSPECTIONS/SUPPLEMENTS CONTACT ROBERT HARVICK AT 800 811-4832XT48011 *****COPY OF ESTIMATE PROVIDED TO VECHICLE OWNER***** FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL► T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMAR.KET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/_ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. ESTIMATE CALCULATED USING A PRESET USER THRESHOLD AMOUNT FOR THE PAINT AND MATERIAL COST. 3 10/25/2004 AT 02:38 PM 0098212362 61346 THE HARTFORD WPLCSC CI 4200 PARK BL PMB # 244 OAKLAND, CA 94602 (800)811-4832 FAX: (510)530-0270 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: ROBERT HARVICK 10/25/2004 02:35 PM ADJUSTER: ANDREW BRAND (800)811-4832 INSURED: NASSER BARA.BI CLAIM #0058212362 OWNER: NASSER BARABI POLICY #57PH 257615 ADDRESS: 4067 HAPPY VALLEY RD DATE OF LOSS: 09/09/2004 AT 08:35 AM LAFAYETTE, CA 94549 TYPE OF LOSS: COLLISION DAY: (925)286-3230 POINT OF IMPACT: 6. REAR EVENING: (925)284-7199 INSPECT PROFESSIONAL AUTOMOTIVE ENTERPRI REPAIRSHOPLOCATION: 3331 MT.DIABLO BL LAFAYETTE, CA 94549 REPAIR PROFESSIONAL AUTOMOTIVE ENTERPRI BUSINESS: (925)283-2160 FACILITY: 3331 MT.DIABLO BL 5 DAYS TO REPAIR LAFAYETTE, CA 94549 LICENSE # 68-0054176 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN VIN: WDBLK70G52TlO7400 LIC: 4VQZ580 CA PROD DATE: ODOMETER: 31212 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS AUTO LEVEL CLIMATE CONTROL THEFT DETERRENT/ALARM STEERING WHEEL CONTROLS DUAL MIRRORS TRACTION CONTROL FOG LAMPS CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER PASSENGER SEAT POWER MIRRORS ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES ROLL BAR POSITRACTION LEATHER SEATS BUCKET SEATS ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR ' PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2* RPR BUMPER COVER 3.2L, 4.3L W/AMG 1.0* 2.4 3 ADD FOR CLEAR COAT 1.0 4 S01 REPL RT REAR RAIL RIVET 1 0.70 5 O/H BUMPER ASSY 2.0 6* S01 REPL REINFORCEMENT 1 76.00 INCL.* 7* S01 REPL RT UPPER RAIL 1 14.00* 8 TRUNK LID 9 REPL TRUNK LID CONVERTIBLE 1 348.00 2.5 2.1 10 OVERLAP MAJOR ADJ. PANEL -0.4 1 i 1 > a 10/25/2004 AT 02:38 PM 0098212362 61346 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------- 11 ADD FOR CLEAR COAT 0.3 12 ADD FOR UNDERSIDE(COMPLETE) 1.0 13 REPL EMBLEM MERCEDES STAR 1 6.50 0.3 CONVERTIBLE 14 REPL NAMEPLATE CLK430 1 27.00 0.3 15 REPL EMBLEM GROMMET 3 1.20 0.3 16* S01 REPL SEAL 1 1.50* INCL. 17* S01 REPL TRUNK LID TRIM RETAINER 6 9.00* 18 CONVERTIBLE/SOFT TOP 19* RPR TOP COVER 3.0* 2.1 20 OVERLAP MINOR PANEL -0.2 21 ADD FOR CLEAR COAT 0.4 22* R&I MOLDING REAR 1.5* 23 QUARTER PANEL 24 BLND RT QUARTER. PANEL 1.3 25 BLND LT QUARTER PANEL 1.3 26 BLND FUEL DOOR 0.2 27 R&I FUEL DOOR 0.3 28 R&I RT LOWER MOLDING 0.2 29 R&I LT LOWER MOLDING 0.2 30 R&I RT WINDOW MOLDING 0.4 31 R&I LT WINDOW MOLDING 0.4 32 REAR LAMPS 33 REPL RT TAIL LAMP ASSY 1 107.00 0.8 34 R&I LT TAIL LAMP ASSY 0.8 N 35 REPL RT TAIL LAMP ASSY 1 74.00 INCL. 36 S01 REPL SUPPORT BRACKET BOLT 2 1.40 37 REAR BODY 38* RPR REAR BODY PANEL 4.0* 1.5 39 OVERLAP MAJOR ADJ. PANEL -0.4 40 ADD FOR CLEAR COAT 0.2 41# FLEX ADDITIVE 1 8.00 42# **COPY OF ESTIMATE PROVIDED TO 1 43# VECHICLE OWNER** 1 44 S01 PILLARS, ROCKER & FLOOR 45* S01 R&I RT GROUND EFFECTS 4.31 5.5 0.5* LITER 46* S01 R&I LT GROUND EFFECTS 4.3, 5.5 0.5* LITER 47# S01 REPL ROCKER MLDG CLIPS 4 7.40 48 S01 ELECTRICAL 49* S01 R&I ANTENNA MAST BASE 0.3* 50# S01 DRILLHOLES IN DECK LID 1 1.0 51# S01 REAR BODY PULL 1 1.0 ------------------------------------------------------------------------------- SUBTOTALS ==> 681.70 21.3 12.8 LINE 35 LITE HAS CRACK ON THE INNER STRUCTURE 2 10/25/2004 AT 02:38 PM 0098212362 61346 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN PARTS 681.70 BODY LABOR 21.3 HRS @$ 70.00/HR 1491.00 PAINT LABOR 12.8 HRS @$ 70.00/HR 896.00 PAINT SUPPLIES 350.00 ---------------------------------------------------- SUBTOTAL $ 3418.70 SALES TAX $ 1031.70 @ 8.7500% 90.27 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 3508.97 ADJUSTMENTS: DEDUCTIBLE 500.00 ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 3008.97 THIS IS NOT AN AUTHORIZATION TO REPAIR.REPAIRS MUST BE AUTHORIZED BY VECHICLE OWNER.PRESENT THIS ESTIMATE TO REPAIR FACILITY OF YOUR CHOICE.NO SUPPLEMENTS WILL BE HONORED BY THE HARTFORD WITHOUT PRIOR APPROVAL,REINSPECTION AND COMPLETE INVOICES FOR. THE ENTIRE REPAIR. IF THERE IS NO LABELING OF PART TYPE IN THE DESCRIPTION COLUMN,IT IS ASSUMED TO BE NEW-OEM. FOR ALL REINSPECTIONS/SUPPLEMENTS CONTACT ROBERT HARVICK AT 800 811-4832XT48011 *****COPY OF ESTIMATE PROVIDED TO VECHICLE OWNER***** 3 10/25/2004 AT 02:38 PM 0098212362 61346 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2002 BENZ CLK43 0 8-4.3L-FI 2D CNVT BROWN ------------------------------------------------------------------------------- NO. OP. DESCRIPTION • QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- ------ ADDED ITEMS ------- 4 S01 REPL RT REAR RAIL RIVET 1 0.70 6* S01 REPL REINFORCEMENT 1 76.00 INCL.* 7* S01 REPL RT UPPER RAIL 1 14.00* 16* S01 REPL SEAL 1 1.50* INCL. 17* S01 REPL TRUNK LID TRIM RETAINER 6 9.00* 36 S01 REPL SUPPORT BRACKET BOLT 2 1.40 44 S01 PILLARS, ROCKER & FLOOR 45* S 01 R&I RT GROUND EFFECTS 4.3, 5.5 LITER 0,5* 46* S01 R&I LT GROUND EFFECTS 4.3, 5.5 LITER 0,5* 47## S01 REPL ROCKER MLDG CLIPS 4 7.40 48 S01 ELECTRICAL 49* S01 R&I ANTENNA MAST BASE 0,3* 50# Sol DRILLHOLES IN DECK LID 1 1.0 51# S01 REAR BODY PULL 1 1.0 ------------------------------------------------------------------------------- SUBTOTALS =_> 110.00 3.3 0.0 PARTS 110.00 BODY LABOR 3.3 HRS @$ 70.00/HR 231.00 ---------------------------------------------------- SUBTOTAL $ 341.00 SALES TAX $ 110.00 @ 8.75000 9.63 ADDITIONAL SUPPLEMENT TAXES -0.01 ---------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $ 350.62 NET COST OF SUPPLEMENT $ 350.62 ESTIMATE 3158.35 ROBERT HARVICK SUPPLEMENT S1 350.62 ROBERT HARVICK -------- TOTAL ADJUSTMENTS $ 500.00 WORKFILE TOTAL $ 3508.97 NET COST OF REPAIRS $ 3008.97 5 Requested By Robin Brown on 11/05/2004 at 02:22:33 PM Claim Number -OPA0001657611 Policy Number :57 PH 257615 Insured Name :ROSE & NASSER BARABI DASTMALCHI Claimant(s) ROSE & NASSER BARABI DASTMALCHI (YJS KAC 15284) ROSE & NASSER BARABI DASTMALCHI (YJS KAC 15284 Date of Loss :09/09/2004 08:35:00 Reporting Period :ALL f , Summary of Released Payments Total Indemnity Paid $ 0-3008.97 Total Expense Paid $ :0 Handler :Andrew P .Brand Supervisor :Adolfo Quintana Type Of Report :ALL yrl ----------------- PAYMENTS ------------------ [09/24/2004 01:12:35 PM PAYMENTS (YJS KAC 15284) PVA ROSE & NASSER BARABI DASTMALCHI] PARTIAL;INDEMNITY;COLL;2658.35; To PROFESSIONAL AUTOMOTIVE and NASSER BARABI ; For Amount $ 2658.35- - COLL LOSS LESS DED $ 500.00 Mailed to- PROFESSIONAL AUTOMOTIVE 3331 MT DIABLO BLVD LAFAYETTE CA 94549 1 1685749 [10/27/2004 05:17*:12 PM PAYMENTS (YJS KAC 15284) PVA ROSE & NASSER BARABI DASTMALCHI] PARTIAL;INDEMNITY;COLL;350.62; To PROFESSIONAL AUTOMOTIVE For Amount $ 350.62 ; SUPPLEMENTAL PAYMENT-COLLISION Mailed to PROFESSIONAL AUTOMOTIVE 3331 MT DIABLO BLVD LAFAYETTE CA 94549 1780828 A ` ccc ' , Page I of I d RIM n- dae X� ti�f h fa https://www.mycccportal-com/cf/images.do?hdn button=Images&requestT'ype=fuIlSizeI... 10/13/2004 Ccs Page 1 of 1 https://www.mycccportai.com/cf/images.do?hdn button=Images&requestType=fullSizeI... 10/13/2004 ccc Page 1 of 1 https://wrww.mycccportal.com/cf/images.do?hdn button=Images&requestType=fullSizeI... 10/13/2004 12-22005 09:02 CCC GMENT 925 335 1421 i �.1 F.01 \K f "Naiunty Administrator on iC1 Risk Management Division Costa 2530 kndd Drive,Suite 140 Countv Fax Number {925}335-1421 Martinez,California 04553 ow w'w s Y i mrd/ a a f JAN 2 FAXMESSAuz C UPERV bu III- (WTPA TPAs HSI tjw� rd I DA TE. 1�j Fax: t t 4 I 1 ax: 33-!5-1.421. `hone: SUBJECT.- Claimant: 7jov'— 7" Claim# � I Date of.Loss: G'\-01- Number ',---0Number of pages including this cover pace: Message: �'�� i r a 1 1 i I i I i -.9090M ;�V 4 PLEASE NthTE: The infarmatio77 contained in this facsimile niessagre n2ay be cof fidential and/or legally privileged infort77crtion intended. only for the use c�,f the individual or entrn., nar»ed above. If the render cif'this message is not the 7771ended recipiew, Yo7i are hereby notified that the copying dissemination or distribxrtio77 Of c017fidentiCal h?1brinatio7 is strictlypl-ohibiled if you have 77or received all of the pages in this n7ess49e. please contact ine at the above phol7e min7ber. Thank Yo it. 09:02 CCC RISK MANAGMENT BOARD OF SUPER VINutz %jiv 925 :335 1421 P-02 INSTRUCTIONS TO CLAIMANT 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 flm 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 y%W426Wr 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 clanns, Penal Code Sec. 72 at the end of this form. was as*mesa muse wasawaftswas so a asses assesessawass weassawn a a seaman wasswasnanus was a& RE: Claim By: Reserved for Clerk's filing stamp 13 A/cvas& (z Against the Coi&y of Contra Costa or U a JAN24 District) CLERK BOARD OF S (Fill in the name) 'i r SUPERVISORS RT ,0KJTPArY-), AM, The undersigned claftnant hereby maks claim against district in the sum of$ 35 the County of Contra Costa or the above-named 0 •3S..".'and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) CA (D1 2-0 0 _.-V S3 5- 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or inju occ ? (Give full details; use extrapaper if required) kA/v� 4. W1 at Particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 2.-CO.3 F-ci r1 � I' t3q3 What are the names of county or district officers, servants,, or employees causing the damagre or injury? JRN--12--2 5 09:02 CCC RISK MANAGMENT 92%E:71 335 1421 P.Cl 6. what damage or injuries do your claire resulted? (Give Ui extent of injuries or damages claimed. Attach two estimates for auto damage.) 1- \-, 7. How was the amount claimed above computed? (Include the estimated amount of any prospective inj ury or damage.) Ar44, -,��4S - & E, k VV 8. Names and addresses of witnesses, doctors,and hospitals: V\0 T,Q" 9. List the expenditures you made on account of this accident or Mnjury: DATE TME AMOUNT ■■s■•■�•!■s■ss■■■■s■•sea■s■■■■eanew as■E■suits■r■nss■■n■■s■■■si■y■as■■■saswas■■■s■see■l ) .Gov. Cade Sec. 910.2 provides"The claitn shall be ) signed by the clm* ant or by some person on his f7� SEND NOTICES TO: Attorney) Name and address of Attorney kAA ) } (Cl 's Signature) !�S6L-k D A A or } (.Address) Telephone No. Telephone leo. C1.3 2> - S ■i■!i!!•!■!■!■M son■t■so■ ■unman a■n s■■■s■■■■s■■■■■s■■man t Mason■■t 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,adden.dum.s, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■man■■ss+t■■■s!i■■s■!■Massa Mass■■t■■was■■■■s■■s■■!noun ■■■■■■was was■■s■st 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 distxict board or officer, authorized to allow or pay the same if genuine, any fare 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 imprison hent and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000). or by bath such imprisonment and fine. TOTAL P.O i 5 i Requested By Robin Brown on 11/05/2004 at 02 :22 :33 PM Claim Number :PA0001657611 Policy Number :57 PH 257615 Insured Name :ROSE & NASSER BARABI DASTMALCHI Claimant (s) : ROSE & NASSER BARABI DASTMALCHI (YJS KAC 15284) ROSE & NASSER BARABI DASTMALCHI (YJS KAC 15284 Date of Loss :09/09/2004 08:35:00 Reporting Period :ALL **** Summary of Released Payments **** Total Indemnity Paid $ :3008.97 Total Expense Paid $ :0 Handler :Andrew P Brand y Supervisor :Adolfo Quintana y Type Of Report :ALL ------------------ PAYMENTS ------------------ [09/24/2004 01:12:35 PM PAYMENTS (YJS KAC 15284) PVA ROSE & NASSER BARABI DASTMALCHI] PARTIAL;INDEMNITY;COLL;2658.35; To PROFESSIONAL AUTOMOTIVE and NASSER BARABI ; For Amount $ 2658.35 ; COLL LOSS LESS DED $ 500.00 Mailed to PROFESSIONAL AUTOMOTIVE 3331 MT DIABLO BLVD LAFAYETTE CA 94549 1685749 [10/27/2004 05:17:12 PM PAYMENTS (YJS KAC 15284) PVA ROSE & NASSER BARABI DASTMALCHI] PARTIAL;INDEMNITY;COLL;350.62; To PROFESSIONAL AUTOMOTIVE For Amount $ 350.62 ; SUPPLEMENTAL PAYMENT-COLLISION Mailed to PROFESSIONAL AUTOMOTIVE , 3331 MT DIABLO BLVD LAFAYETTE CA 94549 1780828 • R p ` . 1 a 09/23/2004 AT 04:53 PM 0098212362 61346 THE HARTFORD WPLCSC CI 4200 PARK BL PMB # 244 OAKLAND, CA 94602 (800) 811-4832 FAX: (510)530-0270 ESTIMATE OF RECORD WRITTEN BY: ROBERT HARVICK 09/23/2004 04:47 PM ADJUSTER: ANDREW BRAND (800)811-4832 INSURED: NASSER BARABI CLAIM #0098212362 OWNER: NASSER BARABI POLICY #57PH 257615 ADDRESS: 4067 HAPPY VALLEY RD DATE OF LOSS: 09/09/2004 AT 08:35 AM LAFAYETTE, CA 94549 TYPE OF LOSS: COLLISION DAY: (925)286-3230 POINT OF IMPACT: 6. REAR EVENING: (925)284-7199 INSPECT PROFESSIONAL AUTOMOTIVE ENTERPRI REPAIR_SHOP LOCATION: 3331 MT.DIABLO BL LAFAYETTE, CA 94549 REPAIR PROFESSIONAL AUTOMOTIVE ENTERPRI BUSINESS: (925)283-2160 FACILITY: 3331 MT.DIABLO BL 5 DAYS TO REPAIR LAFAYETTE, CA 94549 LICENSE ## 68-0054176 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN VIN: WDBLK70G52T107400 LIC: 4VQZ580 CA PROD DATE: ODOMETER: 31212 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS AUTO LEVEL CLIMATE CONTROL THEFT DETERRENT/ALARM STEERING WHEEL CONTROLS DUAL MIRRORS TRACTION CONTROL FOG LAMPS CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER PASSENGER SEAT POWER MIRRORS ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES ROLL BAR POSITRACTION LEATHER SEATS BUCKET SEATS ALUMINUM/ALLOY WHEELS. ------------------------------------------------------------------ NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT --------------------------------------------------------------- 1 REAR BUMPER 2* RPR BUMPER COVER 3.2L, 4.3L W/AMG 1.0* 2.4 3 ADD FOR CLEAR COAT 1.0 4 O/H BUMPER ASSY 2.0 5 TRUNK LID 6 REPL TRUNK LID CONVERTIBLE 1 348.00 2.5 2.1 7 OVERLAP MAJOR ADJ. PANEL -0.4 8 ADD FOR CLEAR COAT 0.3 9 ADD FOR UNDERSIDE(COMPLETE) 1.0 1 s e . s 09/23/2004 AT 04:53 PM 0098212362 61346 ESTIMATE OF RECORD 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN ---------------- -------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 10 REPL EMBLEM MERCEDES STAR 1 6.50 0.3 CONVERTIBLE 11 REPL NAMEPLATE CLK430 1 27.00 0.3 12 REPL EMBLEM GROMMET 3 1.20 0.3 13 CONVERTIBLE/SOFT TOP 14* RPR TOP COVER 3 .0* 2.1 15 OVERLAP MINOR PANEL -0.2 16 ADD FOR CLEAR COAT 0.4 17* R&I MOLDING REAR 1.5* 18 QUARTER PANEL 19 BLND RT QUARTER PANEL 1.3 20 BLND LT QUARTER PANEL 1.3 21 BLND FUEL DOOR 0.2 22 R&I FUEL DOOR 0.3 23 R&I RT LOWER MOLDING 0.2 24 R&I LT LOWER MOLDING 0.2 25 R&I RT WINDOW MOLDING 0.4 26 R&I LT WINDOW MOLDING 0.4 27 REAR LAMPS 28 REPL RT TAIL LAMP ASSY 1 107.00 0.8 29 R&I LT TAIL LAMP ASSY 0.8 N 30 REPL RT TAIL LAMP ASSY 1 74.00 INCL. 31 REAR BODY 32* RPR REAR BODY PANEL 4.0* 1.5 33 OVERLAP MAJOR ADJ. PANEL -0.4 34 ADD FOR CLEAR COAT 0.2 35# FLEX ADDITIVE 1 8.00 36# **COPY OF ESTIMATE PROVIDED TO 1 37# VECHICLE OWNER** 1 ------------------------------------------------------------------------------- SUBTOTALS =_> 571.70 18.0 12.8 LINE 30 LITE HAS CRACK ON THE INNER STRUCTURE PARTS 571.70 BODY LABOR 18.0 HRS @$ 70.00/HR 1260.00 PAINT LABOR 12.8 HRS @$ 70.00/HR 896.00 PAINT SUPPLIES 350.00 ---------------------------------------------------- SUBTOTAL $ 3077.70 SALES TAX $ 921.70 @ 8.7500% 80.65 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 3158.35 ADJUSTMENTS: DEDUCTIBLE 500.00 2 V 09/23/2004 AT 04:53 PM 0098212362 61346 ESTIMATE OF RECORD 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 2658.35 THIS IS NOT AN AUTHORIZATION TO REPAIR.REPAIRS MUST BE AUTHORIZED BY VECHICLE OWNER.PRESENT THIS ESTIMATE TO REPAIR FACILITY OF YOUR CHOICE.NO SUPPLEMENTS WILL BE HONORED BY THE HARTFORD WITHOUT PRIOR APPROVAL,REINSPECTION AND COMPLETE INVOICES FOR THE ENTIRE REPAIR. FOR ALL REINSPECTIONS/SUPPLEMENTS CONTACT ROBERT HARVICK AT 800 811-4832XT48011 *****COPY OF ESTIMATE PROVIDED TO VECHICLE OWNER***** FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. ESTIMATE CALCULATED USING A PRESET USER THRESHOLD AMOUNT FOR THE PAINT AND MATERIAL COST. 3 , 10/25/2004 AT 02:38 PM 0098212362 61346 THE HARTFORD WPLCSC CI 4200 PARK BL PMB # 244 OAKLAND, CA 94602 (800) 811-4832 FAX: (510)530-0270 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: ROBERT HARVICK 10/25/2004 02:35 PM ADJUSTER: ANDREW BRAND (800)811-4832 INSURED: NASSER BARABI CLAIM #0098212362 OWNER: NASSER BARABI POLICY #57PH 257615 ADDRESS: 4067 HAPPY VALLEY RD DATE OF LOSS: 09/09/2004 AT 08:35 AM LAFAYETTE, CA 94549 TYPE OF LOSS: COLLISION DAY: (925)286-3230 POINT OF IMPACT: 6. REAR EVENING: (925)284-7199 INSPECT PROFESSIONAL AUTOMOTIVE ENTERPRI REPAIR_SHOP LOCATION: 3331 MT.DIABLO BL LAFAYETTE, CA 94549 REPAIR PROFESSIONAL AUTOMOTIVE ENTERPRI BUSINESS: (925)283-2160 FACILITY: 3331 MT.DIABLO BL 5 DAYS TO REPAIR LAFAYETTE, CA 94549 LICENSE # 68-0054176 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN VIN: WDBLK70G52T107400 LIC: 4VQZ580 CA PROD DATE: ODOMETER: 31212 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS AUTO LEVEL CLIMATE CONTROL THEFT DETERRENT/ALARM STEERING WHEEL CONTROLS DUAL MIRRORS TRACTION CONTROL FOG LAMPS CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER PASSENGER SEAT POWER MIRRORS ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES ROLL BAR POSITRACTION LEATHER SEATS BUCKET SEATS ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2* RPR BUMPER COVER 3.2L, 4.3L W/AMG 1.0* 2.4 3 ADD FOR CLEAR COAT 1.0 4 S01 REPL RT REAR RAIL RIVET 1 0.70 5 O/H BUMPER ASSY 2.0 6* S01 REPL REINFORCEMENT 1 76.00 INCL.* 7* S01 REPL RT UPPER RAIL 1 14.00* 8 TRUNK LID 9 REPL TRUNK LID CONVERTIBLE 1 348.00 2.5 2.1 10 OVERLAP MAJOR ADJ. PANEL -0.4 1 r 10/25/2004 AT 02:38 PM 0098212362 61346 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 11 ADD FOR CLEAR COAT 0.3 12 ADD FOR UNDERSIDE(COMPLETE) 1.0 13 REPL EMBLEM MERCEDES STAR 1 6.50 0.3 CONVERTIBLE 14 REPL NAMEPLATE CLK430 1 27.00 0.3 15 REPL EMBLEM GROMMET 3 1.20 0.3 16* S01 REPL SEAL 1 1.50* INCL. 17* S01 REPL TRUNK LID TRIM RETAINER 6 9.00* 18 CONVERTIBLE/SOFT TOP 19* RPR TOP COVER 3.0* 2.1 20 OVERLAP MINOR PANEL -0,2 21 ADD FOR CLEAR COAT 0.4 22* R&I MOLDING REAR 1.5* 23 QUARTER PANEL 24 BLND RT QUARTER PANEL 1.3 25 BLND LT QUARTER PANEL 1.3 26 BLND FUEL DOOR 0.2 27 R&I FUEL DOOR 0.3 28 R&I RT LOWER MOLDING 0.2 29 R&I LT LOWER MOLDING 0.2 30 R&I RT WINDOW MOLDING 0.4 31 R&I LT WINDOW MOLDING 0.4 32 REAR LAMPS 33 REPL RT TAIL LAMP ASSY 1 107.00 0.8 34 R&I LT TAIL LAMP ASSY 0,8 N 35 REPL RT TAIL LAMP ASSY 1 74.00 INCL. 36 SO1 REPL SUPPORT BRACKET BOLT 2 1.40 37 REAR BODY 38* RPR REAR BODY PANEL 4.0* 1.5 39 OVERLAP MAJOR ADJ. PANEL -0.4 40 ADD FOR CLEAR COAT 0,2 41# FLEX ADDITIVE 1 8.00 42# **COPY OF ESTIMATE PROVIDED TO 1 43# VECHICLE OWNER** 1 44 S01 PILLARS, ROCKER & FLOOR 45* S01 R&I RT GROUND EFFECTS 4.3, 5.5 0.5* LITER 46* S01 R&I LT GROUND EFFECTS 4.3, 5.5 0.5* LITER 47# S01 REPL ROCKER MLDG CLIPS 4 7.40 48 S01 ELECTRICAL 49* S01 R&I ANTENNA MAST BASE 0.3* 50# S01 DRILLHOLES IN DECK LID 1 1.0 51# S01 REAR BODY PULL 1 1.0 ------------------------------------------------------------------------------- SUBTOTALS =_> 681.70 21.3 12.8 LINE 35 LITE HAS CRACK ON THE INNER STRUCTURE 2 a , s r 10/25/2004 AT 02:38 PM 0098212362 61346 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN PARTS 681.70 BODY LABOR 21.3 HRS @$ 70.00/HR 1491.00 PAINT LABOR 12.8 HRS @$ 70.00/HR 896.00 PAINT SUPPLIES 350.00 ---------------------------------------------------- SUBTOTAL $ 3418.70 SALES TAX $ 1031.70 @ 8.7500% 90.27 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 3508.97 ADJUSTMENTS: DEDUCTIBLE 500.00 ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 3008.97 THIS IS NOT AN AUTHORIZATION TO REPAIR.REPAIRS MUST BE AUTHORIZED BY VECHICLE OWNER.PRESENT THIS ESTIMATE TO REPAIR FACILITY OF YOUR CHOICE.NO SUPPLEMENTS WILL BE HONORED BY THE HARTFORD WITHOUT PRIOR APPROVAL,REINSPECTION AND COMPLETE INVOICES FOR THE ENTIRE REPAIR. IF THERE IS NO LABELING OF PART TYPE IN THE DESCRIPTION COLUMN,IT IS ASSUMED TO BE NEW-OEM. FOR ALL REINSPECTIONS/SUPPLEMENTS CONTACT ROBERT HARVICK AT 800 811-4832XT48011 *****COPY OF ESTIMATE PROVIDED TO VECHICLE OWNER***** 3 ! j 10/25/2004 AT 02:38 PM 0098212362 61346 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2002 BENZ CLK430 8-4.3L-FI 2D CNVT BROWN ------------------------------------------------------------------------------- NO. OP. DESCRIPTION IQTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- ------- ADDED ITEMS ------- 4 S01 REPL RT REAR RAIL RIVET 1 0.70 6* S01 REPL REINFORCEMENT 1 76.00 INCL.* 7* S01 REPL RT UPPER RAIL 1 14.00* 16* S01 REPL SEAL 1 1.50* INCL. 17* S01 REPL TRUNK LID TRIM RETAINER 6 9.00* 36 S01 REPL SUPPORT BRACKET BOLT 2 1.40 44 S01 PILLARS, ROCKER & FLOOR 45* S01 R&I RT GROUND EFFECTS 4.3, 5.5 LITER 0.5* 46* S01 R&I LT GROUND EFFECTS 4.3, 5.5 LITER 0.5* 47# S01 REPL ROCKER MLDG CLIPS 4 7.40 48 S01 ELECTRICAL 49* S01 R&I ANTENNA MAST BASE 0.3* 50# S01 DRILLHOLES IN DECK LID 1 1.0 51# SO1 REAR BODY PULL 1 1.0 ------------------------------------------------------------------------------- SUBTOTALS =_> 110.00 3.3 0.0 PARTS 110.00 BODY LABOR 3.3 HRS @$ 70.00/HR 231.00 ---------------------------------------------------- SUBTOTAL $ 341.00 SALES TAX $ 110.00 @ 8.7500% 9.63 ADDITIONAL SUPPLEMENT TAXES -0.01 ---------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $ 350.62 NET COST OF SUPPLEMENT $ 350.62 ESTIMATE 3158.35 ROBERT HARVICK SUPPLEMENT S1 350.62 ROBERT HARVICK -------- TOTAL ADJUSTMENTS $ 500.00 WORKFILE TOTAL $ 3508.97 NET COST OF REPAIRS $ 3008.97 5 CCC Page 1 of 1 maim .tux :.✓•: ::t::.::x.::>•: ..t•-:.k"-::`.` ASYL4R4s. r aii•��>::::.:+••::•:::,.•;:.::•r:.,a::•}`:•},c..r:.:..:::.}-..,}:a::.}rr+;'.:;c:;:::•:. .rr . v'v,'{.•' ` :.•....,5,}y..;;.C,;.rv............v�•.:.v:.ivv.:�::•r:.�i:ii�}::ir:.:..........:..�:}jir;rrn..:i:}+r? h _ ..... ..., '+'• ..r.3'<rij:?:b1r'�;•:s:L.is}�:i.}i•:t' /! .`.�j + r Y-��� •r•��..r,:.�.:•'fir f.•r: NO .orf}'},:'r:,.:•::::.:.:.. ...'.•' ::x:••' :vr::rv.::n:',,, :.4... :...is:.:rt;;:..n.::iL�!4'::iSif:}'r'•riri:v:::... .:.Y.•.r;r...r�i.-••i:'v'i•........ r :: .Grrr{ yfr S. t:Sn::KFS+r i1fil:+ i W:?•:iji�:rAjr}:.;rii:r::LL-:i..:._..:i:•.':::.?::i.•:::•:•ik}W}..}. -.:rY.i .ice 'fi'''t•/•::::::::.. :`:`r,:;:r}Cj•r..nn:l'Y:'jj::::?:::::�:::j:i:`:j::j::�:`';:�f�'::'t::::}�'xy?: rt+i'iihv:::• :'.::+:{:v 'r`:is:}St.:: kd}}}o;:;r:,.'i.r:'•'t•`:•rL:•':^-' :.'•rX••,i:: •:.rG:.:.'. ::�?••:c`h.';::t?:,;;r,•:.:?:•`.:.:::?..'. ,rr=:Sc'7re';'r.:?S:°•Z'?::<.'•'..'•.'.•.'•l?< ,:{i!},.'.L�. ii::•yrj:'r rj�: ryf{.,4,r eT...;�.. r:::r1::?r{;.+�•.1f:??}?r.;;jr iS.v-•?tv'.}i'7:L`j iY tiff??Z::•r::;:.•?:.} i�j.+F{Y.r{jY;i•$L.rr:::•'i}:'•]v�f,{5.',•#••."'1�:.•:5.:•:;,}: t;;}•tit:•::j•r•,r;;L.}:r:-.:.;?r:�:?"s:;4'i`�;5k�:;:• .• .......:6 F .C,'..ci si:::;'•;•::. few•-�.'�i'�•. },}r.3.:jYt:':i'•"�+':itrt.?:,•`:,•.,.rdGr•:�>`xf�':' MR ......V,X� MIS" n::l . ,. frcl r�: https://www.mycccportal.com/cf/images.do?hdn_button=Images&requestType=fullSizeI... 10/13/2004 • Ccc Page 1 of 1 ♦ M r l https://www.mycccportal.com/cf/images.do?hdn_button=Images&requestType=fullSizeI... 10/13/2004 CCC Page 1 of 1 a rFY.rY. 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All Section references are to ) The copy of this document mailed to you is your California Govenunent Codes. ) notice of the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), give Pursuant to Government Code Section 913 and ggjpjp 915.4. Please note all "Warnings". S AMOUNT• UNKNOWN �°� J # a CLAIMANT, AUGUSTA► PELLEGRINI U • . JANUARY 24, 2005 ATTORNEY: UNKNOWN DATE RECEIVED. ADDRESS: 64 ROBLE ROAD BY DELIVERY TO CLERK.ON:JANUARY 249 2005 BERKELEY, CA 94705--2838 RECEIVED THROUGH BY MAIL POSTMARKED: INTER-OFFICE MAIL FROM RISK MANAGE- * Clerk of the Board of Su ervisors' TO: Count Counsel ANT MANAGE- FROM: C p Y Attached is a copy of the above-noted claire. JOHN SWEE Irk Dated: .JANUARY 24, 2005 By: Deputy II. MOM: County Counsel:. = TO: Clerk of the Board of Supe i;ors (V,.*KThis claim complies substantially with Sections 910 and 910,2. i { ) 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: �' ' `� �" BDe uty County Coun y . III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. 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. + v �°',r�� " JOHN CLERK, `/y,T� 11 B . De uty Clerk Dated �rw�r. rn �i�w�rrrrn�■�i.rru.. Y 0��1•�N SWEETEN, V.R.I�J�,� = y ? p �/ ' WARNING(Gov. code section 913) I .- li_!- ___,L -- ..,... cisrtrPri nr r1P.nn_gi { This warning does not apply to claims which are not subject to the California Tort Claims Act-such as actions in in 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'c* laim, The County of Contra Cotta does not waive any of its rights under California Tort Claims Act nor does it waive rights under the. statutes of limitations applicably to actions not subject to the California Tort C16ims 'Act* a t \r� C) BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY } r INSTRUCTIONS TO CLAIMANT 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.) Be 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 Cade Sec. 72 at the end of this form. ■■■■■Nunn■■■s■■■■■■■■ss■aanon■■ss■ssss■M■■■aa■Mumma a■a■■■■aasonumansaManus ss■a RE: Claim By: Reserved for Clerk's filing stamp /lq PC Nit Against the County of Contra Costa or } SAN 2 4 District) C�-SR�f �'0TAoUpER�'S RS (Fill in the name) Y TA The undersigned claimant hereby makes claire 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) Al o u4o � 2. where did the damage or injury occur? (Include city and county) 3. How did the damage or 'injury occur? (Give full details,use extra. paper if required) "JiP� At%S :ton 4. What,particular act or omission on the part of county or district officers, servants, or employees`� caro sed the injury or damage? c/A 4 \)t H Lr_ t�J ne 0 5 what are the names of county or district officers, servants or employees causing the damage or injury? Y<5 �b 5 Y r O� V 6. what damage or injuries do your claim resulted? (Give full extent of injuries or damages w claimed. Attach two estimates for auto damage.) 7. How was the amount claimed above computed? clude the estimated amount of any prospective injury or damage.) S. Names and addresses of witnesses, doctors, and hospitals: t;k d4 LCI + 94 9. List the expenditures you made on account of this accident or injury: 1 DATE W TIME AMOU6;52..N r � CAQ 4V slow . � s 6gor ft-CWT,4.43 ■■■■man■■■■Mason■■■■■■■■■■■■■■■sun■■■Nunn RENEE■■■■MEMO■■■■■■monsoon Una■■■■■■ONE man SRI .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 ignature) 61 90) R-ec ELS IF40 04 4A (Address) _ r Telephone No. )Telephone No. L5"' 5n -- CC>4 .1........■........■■man■■■■■■■■■■■■■.........Nunn■onus.....■...■.■.....■NON■■■■■■■■I 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. ■monsoon Kong Nouns■■■■was■■■■■■■■■■■■■■!■■■■■■■■!■■■■■■■■■■■■■■■t■■■■■■■■■ ■■■MKIIIIIIIIIIIII 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. .4p I 12/21/04 TUE 11:08 FAX 415 50' '488 LLL t 1,KAU,�0 — w Y ` t „.r I CLAIM#57304 Dear Penny, As agreed, I send you the list of my"property claims"following the accident my girlfriend (Kadidia Traore) had with Mr.Michael Hayes Nov 30 2004(CLAIM#57304) This list is updated to today's (Dec 21 2004)and includes everything in my knowledge till now. i will let you know asap, if any third party will ask me for money later on (I don't know if the police/County will ask me for any money due to highway cleaning,...etc.) 1),Hyundai Accent(Total Loss) 2) Rental Car Car rented at Avis (Berkeley)-I attach a copy of the "invoice" 3) Pair of Glasses My girlfriend hit her head in the impact and damaged them. i attach an invoice of the glasses she bought few weeks ago($257 out of pocket for her). 4) Coat In the impact,one of the arms had friction with a plastic part of the car and got a big abrasion. Bought at Macys(San Francisco)-Paid about$270-Still looking for receipt, and available to send it to you for vision 51 Tow company Bill(including parking)The invoice I attach is for$580 One more time, this is just for property damages known as of now(no hospital, etc. expenses included). As I said,this was a very busy period for us, and I appreciate the patience you demonstrated. Looking forward to hear from you soon. Sincerely, Augusto Pellegrini 415-5014104 i ^� �y a .^ _. ,. .��. w Y 1-i 21/'U4 lUL 11.�� 1*,aAL ��v s •, 5AN kAMION TOW f. •~`,,,,,'.ff r f..J/r 1 ' SETA C T. SAN RAMON TOW %SAaF-§VWE T OW NN R911UN 3 N.' �4-523 P.O. Box 1606 P.Q. Box 2625 48N) 747-8894 San Ramon,CA •94583 Dublin, CA 94668 (929) 820-6304 (925) 829-4637 t,42'5'43t81;:'6"r34 KIM t1_AV Tlma PM. Requmted EIYA L.L� cation of VBhiale V , __._. SAT F ??/1 3S./N* TIME �j8;rr RM 1-.M� A 3 e-we—1W Lmu Phone Hm. Phone Bus. } r Was& 1 _.._. Mileage 5orv4ce Time 90%Person ❑ainglo Me w1rch, Finish C]Dual Ileo winching T 115h PIr11�11 I .TF1'f- 00 2 SALE r580. b� 0 SpAtch blacks t scurf start ! ACCT! 488866321817M4 0186 r 0 fly r fol TOW 7otu1 Q Madfum Duty tow RESF. RUTH/TILT 08693c1 p ; ar M /Mod /Dolor Odometer • 7 AGRE TO PAY A9t7UE TOTAL AMOUNT 3 v.I,N.0 � f l RCMRD 1 HG TO CRRD NSJUER. ASRE M`LHT sling/H01ATaw (�admd/carrier C3 Flat Tire 0 PUel U Recovery f�'iE,�?::HAt T >lb�?,FEI+IEI T Y r u:i l ijl lt:.!�tR;� Wheel Lift Tow ❑Under Lin Tow 0 lump ftn 0 Lack Ovc -k*reck :ntcle Towed To ` 1yrnant Method �.ri .+• i... _r.1r-rr.r.r Casa 0 Cneex Charge to 1:GNIATI RE wo I p.Date AUK 0 MomDflGaae+�. imarkxCO Ohor 4111juulluuu 0 Mot" Towing pe ❑Kj.;11:U:pv HuquirUri ❑Reloaae Mileage Charge •. )-&bar Charge torogo Charge Z _3 bpertllvr'�Slflnb(utd TfuCk a .• . 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Privacy Statement I Visitor Agreement n��j ter_ �-- l- se&1(�,in4�t.,�,,,,.,,�,,;/�nn�y„+/17gf14/nrt; me bfmi7tmva�tinn—vc� rP 711/2C)C)4. //www UJG1,.0 1 7O lly u.L.LAW uvv�ttt!tom. <J/l V4J�1{.�111„7.11{.ilit.bt�i♦sA�Jbjvyy �,� V ss ...r. 1 -+ �f �� 8 Y Wi l t e��fiA,� ��. �� } `_Aj' '"^ �� CLAD BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY , BOARD ACTION:MARCH 01, 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), give Pursuant to Government Code Section 913 and q fifi ` r 915.4. Please note all "Warnings" c.( p AMOUNT: UNKNOWN " CLAIMANT: K. IDIA TRAORE � � { ATTORNEY: UNKNOWN DATE RECEI"V"ED: JANUARY 24, 2005 ADDRESS: 4 ROBLE ROAD BY DELIVERY TO CLERK ON: JANUARY 24, 2005 BERKELEY, CA 94705-2838 RECEIVED THROUGH BY MAIL POSTMARKED: TNTER-0FFTCCE MATT. FROM RISK MANAGE- FROM: Clerk of the Board of Su� y ervisors TO: Count Counsel MENT Attached is a copy of the above-noted claim. JOHN S WE T N) Jerk Dated; JANUARY 24, 2005 y p B Deput y II. FROM: County Counsel:. = TO: Clerk of the Board of Su ervisors O 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. By. ���- Deputy County Cour 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. OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O other: i I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date, Dated. M Deputy Clerk944�� JOHN SWEETEN, CLERK, y r Zr WARNING(Gov. code section 91.3) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or deposi 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 fu prepaid a certified copy of this Board order and Notice to Claimant, addressed to the claimant as shown above. Dated:/%L44& A? ���►�oHN SWEETEN, CLERK By Deputy Cly r S i BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY ( ' s low INSTRUCTIONS TO CLAIMANT A A. A claim relatingto a cause of action for death or for injury to person or to personal property or growing crops shall be resented not later than six months after the accrual of the cause of gr' g P p 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 945 5 3. 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. ...............................................................:..............t RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or ) g JAN 2 4 6 District) CLERK BOARD OF �,���.���, SUPER�SCRS (Fill in the name) ) o �-q Jnr The undersigned claimant herebymakes 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) V- yl:���- CLJ 2. where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details;use extra paper if required) &2 a&Qctj 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 5 what are the names of county or district officers, servants, or employees causing the damage or injury? 4 1 Y 4 6. ,what damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) fzt, 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) -ohm 4J 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 ■.■■■■■■■monsoons man.■■■............................■............■......■■■■■■■■■■■■I ) .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 ) -cam., C.� .. (Clau- nant's Signature) --~-- CT a rl� cj v (Address) Telephone No. )Telephone No. 5_0 I Q' ....:...............mass.■...............................................■■■■■■■■■.■, 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. ■■■■■■■■■■■■■■■■■■■■moos■■■■MEN■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■moo■■■■■■■■t NOTICE: Section 72 of the Venal 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. 1L6%�1.U J co 1 7— boo .a • f T, M •. • �. r•w•• �..�'•nL•! �..{e.-i_'l.. .�,.�1 �..�...t ..�� •ew.• • ..• ••.h�r �••.a•.. sw yy " ,� + �f• .r,.,:�J l:�• �.. � ♦r��� ••"a enu'.t�♦• ;. , f { • "tinmm No. won •- t cn �•• }r ` � • �� � ( �` f .... +r+. •�. r. yrs_. •. .. .. • ...f• w .) ! pmw to Irmn + f f tto � �`�: ? tri �• � --t . 13 cl coo , � � car a = .. �1• „ � r. .. «. ,.•.. .... '.�.....�......h• •. :'•»-•:.y.`,•'�,'�•'Vrriwt".'.ik."•••s,Ni.w•yl;a„^!. `•nw.,:, - - - —-- - .r>•,�.•• .f1 pop 41171. STACITE 1 lrqe-u EXAM ' F-010704*9 MIME •y MuLtwtEs pyo RTE p COPY TOTS ' �of -�----- 0 `• ' ' DD• ��EIC3H'T rtM�T ' YLINDEA'' )CIS -PRISM, BASE SPHERE DEC A 'C FA06 Q 67 L BIFOCAL. ( pFtQQRESSNE _ p�D NITUALM34, o:ev' ciA/• ENV . , ,�/` INT : �:,.• ale- cr+EcKEo:e`► " ••TIN' 1NVy 4� Y•, D GlA5s'. PL:/�SITIC'' C]:BCAATCs+AESjgrl�NT JtNtt-A£Ft-EGT D w1,rrE (3 pCl. W UV: p Ep •BLJINK BtZe ' C3PNCOREV x ' ❑ OTNEA Y' `..� pH,BP101MN X M HmfimX. .' •'•. f ME LA6,091DEB G fN'F AR_ r R 11 TE lA8'CAOEii OA�'f"\ ,�.. GquDp EYE fr 9�q�QgE ` ' •' !•~ P i V\f'�vw IAV. r L.6^ ►fly+ ' E SKU •• ' BHAp� '•' .. . . .'•'. .•,.•�•.. °• . .•. . .•.• •. ` .. .•. PUW .:lot.EGI8 ER'INSTRUCt10 9.' CMJCEBIC. :M r EXAM FRAME :'' ,� r «0!- ` •t fir"''" '' •: ':" '' :,� '• �' 1.JINT I COAT SuNkASSES PA• I�CJI�1 i. "' .... ..•.:. r. i SUBTCTAI -►�' ', DISCOUNT OzyvttFt av I TAX f T•,:; 'i Yaut tia Dme ' .. _TOTAL .. �1 ,' rf You*�"per4d� . aEPo�tiT '; • •BALANCE DUE .BANK CJ�SK CK CARD CERT, PARTY SR-EO FORM-t04M.yds •. 1. The damage/injury incurred on the 11/30/2004 between 8:3Dam and 9:00am. 2. The damage/injury incurred on highway 1680 South between Walnut Creek, CA and San Ramon, CA. 3. 1,Kadidia Traore, was driving toward San Ramon, CA when Michael Hayes's vehicle hit my car from behind. The impact pushed my vehicle into the"highway separation wall."I used my right arm to protect my head. The airbags came out and my vehicle spun-out of control before stopping. 4. Michael Hayes' vehicle hit my car from behind while in movement. 5. Michael Hayes4)1_2,6�r 6. The following damage or injuries resulted(as of January 14��� • Damaged glasses(see invoice) : $257 • Damaged coat(Right arm had friction with a plastic part of the car and got a big abrasion): $204 (the receipt will be available from Macy's in 2 weeks) • Ambulance costs: see attached invoice • Medical services (John Muir Hospital): see attached invoice • Subsequent hospital visit related to the accident: see attached invoice • 2 days of work missed: $191.57 x 2=$383.14 It should be noted that as a result of the accident, I missed work on the 11/30/2004, day of the accident,and on the 12/01/2004, day subsequent to the accident—time that I spent going to the hospital for second medical verification, looking for the towed car location, looking for the police report, and getting myself back together after the emotional stress and the body injuries caused by the accident(see medical report). I have a gross salary of $50,000-per year or 191:57 per day,which is calculated as $50,000/(365days— (2days, Saturday and Sunday, *52 weeks). • For body injuries detail,please make reference to the medical report you will get from John Muir Hospital • Distress and pain for the contusions 7. See attached receipts(The receipts are inclusive of expenses sustained with third parties till this point—I will let you know of any additional expense that may arise in the future) 8. Doctor David Soohoo, John Muir Medical Center, 1601 Ygnaci Valley Road, Walnut Creek, ca 94599-telephone 925 939 3000 9. See point 6 for detail Best regards, Kadidia M. Traore ALTA BATES MEDICAL ASSOCIATES PATIENT NAME x P.O.fox 255386 Sacramento,CA 95865-5386 KADIDIA TRAORE [FAOUNT NUMBER AMOUNT DUE I I VI2483328 $164.00 OUNT PAID Control#6-114-2-182 PATIENT/GUARANTOR ALTA BATES MEDICAL ASSOCIATES PO Box 255386 SACRAMENTO,CA 95865-5386 KADIDIA TRAORE 64 ROBLE ROAD BERKELEY,CA 94705 PAGE: 1 OF 1 MAKE CHECKS PAYABLE TO: ALTA BATES MEDICAL ASSOCIATES FOR ASSISTANCE CALL: 916-854-6890 or ❑ Check here for 00 card payment,insurance information,address changes,and complete form on reverse side. 866-233-5330 DETACH AND RETURN UPPER PORTION WITH PAYMENT ........... ....... .......... .......... ............... N ': ... .............. Q1' Vii" ?" ::.: :. ...... ........ RAT ...... k. ...... BE PROV M­FIDER-.-" : ?k : : E :CE I .......... :V •§. . ------- ---------------- ....... .......... ........ Patient Name:KADIDIA TRAORE Invoice#19477224 SHINE-NEE TENG MD 12/91/2004 728.85 99203 OFFICE/OUTPATIENT VISIT,NEW $164.00 Patient Responsibility $164.00 Total Patient Responsibility $164.00 A Vii.. SMA :. : "... N. . ..:....::. RT `...... QUA `'.'': N::.. AS A SERVICE TO OUR PATIENTS,YOUR INSURANCE HAS BEEN BILLED FOR THE SERVICES YOU RECEIVED. IF YOUR INSURANCE HAS NOT PAID WITHIN 30 DAYS,PAYMENT FOR THESE SERVICES WILL BE YOUR RESPONSIBILITY. PLEASE MAKE PAYMENT IN 30 DAYS IF YOUR INSURANCE HAS NOT PAID. CURRENT BAL.OVER BAL.OVER BAL.OVER BAL.OVER PAYMENTS OR CHARGES RECEIVED BALANCE 30 DAYS 60 DAYS 90 DAYS 120 DAYS AFTER STATEMENT CLOSING DATE ARE PENDING INSURANCE 0.00 0.00 0.00 0.00 0.00 NOT REFLECTED ON THIS STATEMENT PATIENT RESPONSIBILITY $164.001 0.00 0.00 Q.00 0.00 STATEMENT CLOSING DATE: 12/09/2004 �qi y'�-,{}(�,,�) �{,^,� M .TO•��.+ .I.'". �.(,/� �e . ER. R '•' '1'.Y.7S'"A\'M'r•`••••• . •.A `.�4'.`:R` .' •. ::TO MAY . T �? O T AMOUNT DUE BY: 01/03/2005 $164.00 155 155 e w r C7-01080*01*002057—EO-04356-30041—ACN 11SNO CFEB02-0308213 UNITED HEALTHCARE INSURANCE COMPANY M UnitedHealthcard TAMPA- SERVICE CENTER .P 0 BOX 740800 A UnitWHeahh Group Company ATLANTA, GA 30374-0800 PHONE: (877) 604-0568 VISIT WWW.MYUHC.COM FOR SELF'—SERVICE PAGE: 1 of 2 DATE: 12r21r04 ID #:A 901228629 .�•� EMPLOYEE: KADIDIA TRAORE CONTRACT: 0701444 —= BENEFIT P LAN:ERNST & YOUNG KADIDIA TRAORE EXPLANATION -- +54 ROBLE RD. - OF BENEFITS BERKELEY CA 94705 SERVICE DETAIL WE Wf .i KADIDIA EE JOHN MUIR MEDICAL 0568710201 OP MISC. SERVICES 11/30/04 1177.25 965.35 50.00 100% 915.35* D2 TOTAL 1177.25 9+5.35 50.00 915.35 QN PLAN PAYS 915.35 ** PATIENT PAYS 50.00 KADIDIA EE BAY IMAGING 0719475301 RADIOLOGY SERVICES 11/30/04 33.00 11.22 100% 11,22* D1 TOTAL 33.00 11.22 11.22 QN PLAN PAYS 11.22 ** PATIENT PAYS 0.00 (*} INDICATES PAYMENT ASSIGNED TO PROVIDER * DEFINITION: "PATIENT PAYS" IS THE AMOUNT, IF ANY, OWED YOUR PROVIDER. THIS MAY INCLUDE AMOUNTS ALREADY PAID TO YOUR PROVIDER AT TIME OF SERVICE. REMARK CODE(S) LISTED BELOW ARE REFERENCED IN THE "SERVICE- DETAIL" SECTION UNDER THE HEADING "REMARK CODE" (D2 } THANK YOU FOR USING A NETWORK PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL. WE HAVE APPLIED THE CONTRACTED FEE, THE PATIENT IS NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE AMOUNT CHARGED BY THE PHYSICIAN OR HEALTH CARE PROFESSIONAL AND THE AMOUNT ALLOWED BY THE CONTRACT. HOWEVER, THE PATIENT IS RESPONSIBLE FOR ANY DEDUCTIBLE, COINSURANCE AMOUNTS AND AMOUNTS OVER THE ANNUAL BENEFIT LIMITS FOR THIS SERVICE, UP TO THE ELIGIBLE EXPENSE. (QN ) YOUR CLAIM MAY HAVE BEEN SEPARATED FOR PROCESSING PURPOSES. ANY ADDITIONAL CHARGES WILL BE PROCESSED AS SOON AS POSSIBLE. (D1 } THANK YOU FOR USING A NETWORK PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL. WE HAVE APPLIED THE CONTRACTED FEE. THE PATIENT IS NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE AMOUNT CHARGED BY THE PHYSICIAN OR HEALTH CARE PROFESSIONAL AND THE AMOUNT ALLOWED BY THE CONTRACT. HOWEVER, THE PATIENT IS RESPONSIBLE FOR ANY DEDUCTIBLE, COINSURANCE AMOUNTS AND AMOUNTS OVER THE ANNUAL BENEFIT LIMITS FOR THIS SERVICE, UP TO THE ELIGIBLE EXPENSE. rouggggrg war,r / .a/i i JOHN MUIR MEDICAL $915.35 BAY IMAGING $11.22 FAMILY $0.00 $0.00 KADIDIA EE $0.00 $0.00 PLAN YEAR FAMILY: $3000.00 FAMILY: $600.00 2004 INDIV: $1500.00 INDIV: $300.00 A REVIEW OF THIS BENEFIT DETERMINATION MAY BE REQUESTED BY SUBMITTING YOUR APPEAL TO US IN WRITING AT THE FOLLOWING ADDRESS: UNITEDHEALTHCARE APPEALS, P.O. BOX 30432, SALT LAKE CITY, UT 84130-0432. THE REQUEST FOR YOUR REVIEW MUST BE MADE WITHIN 180 DAYS FROM THE DATE YOU RECEIVE THIS STATEMENT. IF YOU REQUEST A REVIEW OF YOUR CLAIM DENIAL, WE WILL COMPLETE OUR REVIEW NOT LATER THAN 30 DAYS AFTER WE RECEIVE YOUR REQUEST FOR REVIEW. YOU MAY HAVE THE RIGHT TO FILE A CIVIL ACTION UNDER ERISA IF ALL REQUIRED REVIEWS OF YOUR CLAIM HAVE BEEN COMPLETED. INSURANCE FRAUD ADDS MILLIONS TO THE COST OF HEALTH CARE, IF SERVICES ARE LISTED WHICH YOU DID NOT RECEIVE OR SERVICE YOU WERE TOLD WOULD BE FREE, CALL (877) 604-0568. FURTHER EXPLANATION OF BENEFITS INFORMATION IS ON CONTINUATION PAGE(S) THIS IS NOTA BILL • MAKE ► ► SAN _,AMON VALLEY FIRE PROTECTION PO BOX 26911.0 SACRAMENTO, CA 95826-9110 FOR BILLING INQUIRIES CALL: (800) 906-6552 7D Pacific Standard Time 04-91141 12/14/2004 12/28/2004 $614.00 INCIDENT NO. 04006193 ► 1r. PLEASE ► REMIT fi3'Y� „. #BWNDRNQ *** WM81214A MIXED AADC 928 #WM80U04/91141//2# 4000000401 01 0003 0116 II�I�� I�I�I �I���I�I�II��I�I��� �II���IIII������IIII���I��I�I ll�l � l��ll � lll ��ll���l�ll��l���ll�l��l��ll���l��l�l��ll KADIDIA TRAORE SAN RAMON VALLEY FIRE PROTECTION 64 ROBLE RD PO BOX 269110 BERKELEY, CA 94705-2838 SACRAMENTO, CA 95826-9110 s PL.F.A.SE RETURN THIS PORTION V%ATH YOUR PAYMENT SEE REVERSE SIDE FOR ADDITIONAL INFORMATION INVOICE, INCIDENT NO. 04006193 Page 1 of 1 RUN NO. 04-91141 DATE OF SERVICE: 11/30/2004 DESCRIPTION QUANTITY COST PER UNIT TOTAL CHARGE Basic Emergency Ambu 1 560.00 560.00 Mileage 6 9.00 54.00 This bill is separate from your hospital bill. You are responsible for all charges. Phase inform us of any insurance coverage, Medicare or MediCal. A Este cobro es separado de la cuenta del hospital. Usted es rosponsable par todas los cargos. Favor de Informanos de cualquler seguro, que usted tenga, o Medicare o MediCal. $614.00 PICKUP LOCATION: 680 LIVORNA DROPOFF LOCATION: John Muir Medical Center This bill is seperate from your hospital bill. Please inform us of any insurance coverage, Medicare or Medicaid/Cal. Este cobro es separado de la cuenta del hospital. Favor de informanos de cualquier seguro, que usted tenga, o Medicare o Medical. SAN RAMON VALLEY FIRE PROTECTION PATIENT: TRAORE, KADIDIA PO BOX 269110 BIRTHDATE: 10/6/1981 SACRAMENTO,CA 95826-9110 FOR BILLING INQUIRIES CALL(800)906-6552 Pacific Standard Time r.' h CLAIM a2 aS BOARD OF SUPERVkISORS OF CONTRA COSTA COUNTY � BCH 01, 2005 BOARD ACTION:, Claim Against the County, or District governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), give Pursuant to Government Code Section 913 and 3 . IX 915.4. Please note all"warnings". 4 r AMOUNT. $59000,00 JAN 2 20lub CLAIMANT: RHONDA COLLINS COUNTY MARTINEZ CALW. ATTORNEY: UNKNOWN DATE RECEIVED: JANUARY ' 28, 2005 . � N: JANUARY 28, 2005 ADDRESS. 2732 IVY LAN BY DELIVERY TO CLERK C� ANTIOCH, CA 94531 HAND DELIVERED BY MAIL POSTMARKED: D: FROM: Clerk of the Board of Supervisors TO: County Counsel O p Attached is a copy of the above-noted claim. JOHN S WEE k Dated: JANUARY 28, 2005 By: Deputy II. MOM: Count y 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). O Other: Dated: ' - + '' By: VDeputy 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. B ARD ORDER: By unanimous vote of the Supervisors present: ( This Claire is rejected in full. O Other: t I certify that this is a true and correct*copy of the Board's Order entered in its minutes for this date. •�� tv44mW#s6 -JOHN SWEETEN CLERK B , De utDated. , y Deputy Clerk WARNING(Gov. code sect on 913) exceptions,ti Subject to certain ons, you have six (6)months from the date this notice was personally served or depos: p only 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 underenalt y of ' that I am now, and at all times herein mentioned,have been a citizen of the Unite(' p y perjury y States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fu prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:. &Y44 0+�" e"JUHN SWEETEN CLERK B Deputy Cl+ t This warning' does not apply to claims which a.re not subject to the California Tort Claims Act-such as actions in in 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. 5 r .. • BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY 4 INSTRUCTIONS TO CLAIMANT 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 forma RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or".J > JAN 2 8an i;n(,Zk, A_a istrict) .Z o (Fill in the name) CLERK BOARD OF SUPERVISORS rnnITOe rncra rn a?D The undersigned claim an makes claim against the County of Contra Costa or the above-named reb district in the sum of$ and in support of this claim represents as follows: 1. Wks n did the d ama or cur? (Give exact date and h�zr�� 2. Where did the damage or injury occur? (Include city and county) Yy\6LK+1nc:�: )04-' aLAO 3. H0�id`tTie- cTamageCez) hfjiuyC occur? (Giveil details; use extra paper if required) cvftutd-,i) cIL6/7 56 Wo LAkt4Co 4. Vparticular act or omission o the part of county or district officers, servants, or emp oyees caused the injury or damage? c���440Lcyof LIE)y�� - "7 1 5 What are the names of county or district officers, servants, or emp oyees causing the damage or injury? F. a fa Y 6. What Jor in damage juries do your claim resulted? {Give full extent of injuries or damages claimed. Attach two estimates for auto damage.} SC-4� 7. How was the amount claimed above computed? {Include the estimated amount of any prospective injury or damage.} 8. Names and addresses of witne es, doctors, and hospitals: %P oO • . 13 9. List the expends es you ma e on account of this accl ent or U4.C^AAo*,000vJ6\oCC— . J DATE TIME AM0'CJNT ■■■■■■■■■■■■■■■■■■■■noun■ago■■■■■■■■■■■■■■■■■■maps■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■not } Gov. Code Sec. 910.2 provides"The claim shall be } signed by the claimant or by some person on his }behalf." SENDNOTICES TO: ,Attorney� Name and address of Attorney } } } {Claimant's Signature} } (Abdress) } Telephone No. ) Telephone N • was■■■■■■■■■■■■■■■■■■■■■■was■■■■■■■■■■■■■■■■■woman Una■■■■■■■■■■■■■■■■■■■■■■■■seasonal 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. ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■mass■■■■■■■■■■■■■■■■■■■■■■■■■■■son nasal 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. Ogre pOwls 26.3? �' �,a-►� 56 ?g ?1_g3 Vek 12� J�tr'a •�• ��,,.�� 'r• hrY .s 1R �our� 'fou ASS ion vpf on tnd� 17 ,/''•- :� �� Ass con �,,, ��,�.. �� ; '' •.�ea M ---�- •Re Con � • Amk s Of n ge M . •Bed •.._1 a ..r»r" e ..-- •GO •"�ea Con esw K r., �.. uK�;Mh�y • ��� Lnµ t pyo ,nds Assessrn e dura P FSG Kn�2o, edMeT r,ik+ ID-T�cs PU�se t: n, Gs 21 '103) 3-60r R���R t�p,�'pG �,pgC) CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY dl* OZZ BOARD ACTION:MARCH O1, 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 onour claim b the Y Y Board of Supervisors. (Paragraph IV below), give n ;s Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings" AMOUNT: $350,00 2e^mi'va4y � µ•F• 11 f i M1 CL �wCi; �� a;, t e CLAIMANT: RUTHA STITTS ATTORNEY: UNKNOWN DATE RECEIVED: FEBRUARY 01, 2005 ADDRESS: 805 BRADFORD DRIVE BY DELIVERY TO CLERK ON: FEBRUARY Ol, 2005 RICHMOND, CA 94806 BY MAIL POSTMARKED: .JANUARY 31, 2005 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN S W Jerk Dated: FEBRUARY 01, 2005� By: Deputy Y Y II. MOM: County Counsel:• = TO: Clerk of the Board of S ervisors ( 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 g notifY in 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 claimants right to apply for leave to present a late claim (Section 911.3). O Other: Dated: BY Deputy CountYCoun 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 Cather: i I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date, Dated'oe 3444JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code se ion 913) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or dep osi 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 postage . California, p g fu. prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. OP Dated:A/042w WVOHN SWEETEN, CLERK By Deputy Cle p Y This warning* does not apply to claims which are not subject to the California Tort Claims Act-such as actions in in 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. i f . What are the names of co ty or district officers servants or employees using the a or injury? } ± ' J co �+r�rrr .�+r+��w�ar�r��rrr+�r.r.ar�r�ra�awrrae�r w�r+�+us.�rws�.��r,r+w�rara.urwsarira�aarr+r.�ra. a� 8. mat ge or in, uries da you claim resulted? (Give extent of in urrff ge darn szes claimed. Attach two estimates for auto dame.too N w IiliMrw+�r��s.war��r�rrrw�w�r�r+��warr �rww�� wrwrM���r�rwwair�+r+�rrrr rrr►�+r��rrwrMll 7. How was the mount claimed above uted? (Include the 7t meted amount of any prospective injury or r amage.) 8. Names and addpesses of witnesses, doctprs and ho pital. ',ist the expenditures you made on account of this accident or injury:. DATE AMOUNT Gov,, Code Sec. 910.2 provides: "The claim gust be signed by the claimant SEND NOTICES TO: (Attorney) 2Ek some person on his behalf." Name and Address of Attorney s aimant's Signature t K (AddressY/ 4-9 0 OWN Telephone No. Telephone N o. a N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to mow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by risonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such 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 iaprisonment and fine. .aim to: HOARD OF auPERVI.90RS OF C�N't'RA OOd'rA OOONTX IIxSTROG'PIUNS TO Q.AIMAI;T A. Claims relating to causes of action for death or for injury to person or to per- sonal property. or growing crops and Mich accrue cn 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 groKing crops and which accrue on or after January 1, 1988, must be presented nit later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code X911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in . Rom 1069 Cotmtq 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 at • � � � � � f � � �t �t �t � �t �t � � s �t �t � � • +� � � f • at � � �t +t � �t � �t �t �t � at � RE: Qlam iBy � j Reserved for Clerk's filing stamp vku Against the County of Contra Costa ) FEB p or ) CLERK ap r�^A 4� G QP�RViSORS District) "11name The undersigned claimant hereby makes claim inst the Comity 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) Z. Where did the damage or injury occur? (Include city and county) M- -7) 3. How did the damage or in occ 3 (Give 1 de ils; use extra paper if required). &` 'L�/I 4. What particular set or omission on the part of county district officers, servants or employees caused the injury or damage? PO (over)