HomeMy WebLinkAboutClaim #545 - SuszczynskiCITY OF PALM DESERT
COMMUNITY SERVICES DIVISION
CITY CLERK OPERATIONS
STAFF REPORT
REQUEST: CLAIM AGAINST THE CITY (#545) BY JERRY E. SUSZCZYNSKI IN THE
AMOUNT OF 135.96
DATE: March 10, 2005
CONTENTS: I. Staff Report
II. Claim No. 545
Recommendation:
By Minute Motion, reject the Claim and direct the City Clerk to so notify the
Claimant.
Background:
Based on a review of the subject Claim and the recommendation of the Claims Adjuster,
Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected.
Discussion of this item should be held in Closed Session pursuant to Government Code Section
54956.9(b), potential litigation.
Submitted by:
HELLE D.
CITY CLERK
Approved:
SS
SEN, CMC
CARLOS L. ORT€GA
CITY MANAGER
rd k
Attachment (as noted)
SHEILA R. GILLI e N, AS
ITY MANAGER
FOR COMMUNITY SER :S/P.I.O.
H:\WPdataIWPDOCSICLAIMS\545-reject staff rpt. wpd
• CITY OF PALM DESERT
CLAIM AGAINST THE CITY OF PALM DESERT RECEIVED
CITY CLERK'S OFFICE
(For Damage(s) to Person(s) or Personal Property) PALM DESERT, CA
Received by: 2005 FEB `9 AM 9: 23
via: U.S. Mail Interoffice Mail Over -the -Counter
ASSIGNED CLAIM NO.
A CLAIM MUST BE FILED WITH THE CITY CLERK OF THE CITY OF PALM DESERT WITHIN SIX
MONTHS AFTER WHICH THE INCIDENT OR EVENT OCCURRED. BE SURE YOUR CLAIM' IS
AGAINST THE CITY OF PALM DESERT, NOT ANOTHER PUBLIC ENTITY. WHERE SPACE IS
INSUFFICIENT, PLEASE USE ADDITIONAL PAPER AND IDENTIFY INFORMATION BY
PARAGRAPH NUMBER. COMPLETED CLAIMS MUST BE MAILED OR DELIVERED TO THE CITY
CLERK, CITY OF PALM DESERT, 73-510 FRED WARING DRIVE, PALM DESERT, CA 92260.
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Palm Desert, California:
The undersigned respectfully submit(s) the following claim and information relative to damage(s) to
person(s) and/or personal property:
1. CLAIMANT INFORMATION:
NAME J/z/Z.)./ / S 524.2-,J
ADDRESS
PHONE NO. DATE OF BIRTH:
SOCIAL SECURI Y NO.!_- -jlgp DRIVER'S LIC N E NO.
2. Name, telephone number and post office address to which claimant desires notices to be
sent, if other than above:
3. Occurrence or event from which the claim arises:
a. DATE: / d - os b. TIME: /Oo c c ,.-, c. PLACE (exact and specific
location) (A.)egs H,wi.v o i.J 24,.rp o GJc S'17 1 t? tic€ r�
d. How and under what circumstances did damage or injury occur? Specify the particular
occurrence, event, act or ommission you claim caused the injury or damage. (Use
additional paper if necessary.) `� o-r- i { o i / n1 5 Tize T 0efv s r�
1),"4,-1/ /a, j -3- + 0 1 c ••r • ..re,,., T
e. What particular action by the City, or its employees, caused the: alleged damage or
injury? N p()-f-d/� i �,.� T�✓�� �va,e
S,9 � a ?o T tic) /� I119 5 ` r.:..rzr
Page I of 2
4. Give a general description of the indebtedness, obligation, injury, damage, or loss incurred
so far as it may be known the time of presentation of the claim. If there were no
injuries, state "no injuries": �q�„s a-,, 2,-
bra
5.
Leua _LA j✓�ias�_
Give the name(s) of the City employee(s) causing the damage or injury:
6. Name and address of any other person(s) injured
7. Name and address of the owner of any damaged property:
8. Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed:
d. Basis for computation of amounts
estimates, etc.)
/35
$ / 35 s-4
claimed (include copies of all bills, invoices,
9. Names and addresses of all witnesses, hospitals, doctors, etc.:
10.Any this additional information, including police reports, which might be helpful in considering
WARNING:IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (PENAL CODE 72;
INSURANCE CODE 556.I).
I have read the matters and statements made in the above claim, and I know the same to be true of
my own knowledge, except as to those matters stated upon information or belief as to such matters
I believe the same to be true. I certify under penalty of perjury that the foregoing is TRUE AND
CORRECT.
Si ned this O C day of
TUOF C
Office of the City Clerk, Palm Desert, California
Page 2 of 2
20 (25 , at C-4-kbPercri 1
SIGNATURE OF CLAIMANT
DOC. NO. DATE FILED
(626) 332-1142
(626) 966-7508
(888) 224:3337
CUSTOMER,. --.
NAME u J
ADDRESS �
PHONE VEHICLE
VEHICLE
NUMBS MILEAGE
TYPE
TUCOMPACKERNYTIRE
818 W. FRONT ST. COVINA, CA.91722
SALES- AR DRV.
PERS LIC. LIC.
2
REC
DELIV
STEMS
LABOR
MT. & BAL.'Z'Z
ALIGN.
PURCHASE ROAD
HAZARD GUAR.?
CUSTOMER COPY
DATE
+ICE NUMBER
DFLIVERY
DRIVER
CASH
CREDIT
CARD
BY
SUB TOTAL
SALES TAX
MISC
DISP TAX
LABOR
TOTAL
EST.1956
ALL APPROVED CHARGE
INVOICES ARE DUE
NEXT 10TM NET
REASON
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