HomeMy WebLinkAboutAgenda Report - February 19, 2020 C-10AGENDA ITEM
CITY OF LODI
COUNCIL COMMUNICATION
TM
AGENDA TITLE: Authorize City Clerk to Grant Request for Leave to Present Late Claim, by Danielle
Macellari, Pursuant to Government Code Section 911.6(a).
MEETING DATE:
PREPARED BY:
February 19, 2020
City Attorney
RECOMMENDED ACTION. Authorize City Clerk to grant request for Leave to Present Late
Claim, filed by Danielle Macellari pursuant to Government Code
Section 911.6(a).
BACKGROUND INFORMATION: Request for Leave to Present Late Claim was filed with the City
Clerk by Danielle Macellari, pursuant to Government Code Section
911.4 on January 13, 2020. A copy of the request to file a
late claim, initial submittals and City's rejection notices are attached. The original submittal was filed
approximately seven weeks after the expiration of the statutory period in which the claim was to have
been filed, based on the March 28, 2019 date of loss. Government Code Section 911.2 requires that
claims against public entities, with limited exception, be filed within six months of the accrual of the action
giving rise to the claim, which in this instance would have been September 28, 2019. Ms. Macellari
submitted her claim on November 14, 2019, which was rejected as untimely on November 20, 2019.
Subsequently, Ms. Macellari filed a duplicate claim for the same matter on December 5, 2019, which was
again rejected as untimely on December 11, 2019. On January 13, 2020, Ms. Macellari's attorney filed
an application of leave to present late claim with the City Clerk.
Statutory exceptions to the claim filing requirements include failure to present the claim through mistake,
inadvertence, surprise or excusable neglect with no resulting prejudice to the public entity; the injured
party was physically or mentally incapacitated during the claim filing period; and the minority or death of
the injured party.
Ms. Macellari application has presented information sufficient to satisfy the statutory element of mistake,
inadvertence, surprise, or excusable neglect (coupled with a lack of prejudice to the City) for the submittal
of a late claim. Therefore, it is recommended that the Council authorize the City Clerk to grant the
request of Danielle Macellari to present a late claim pursuant to Government Code section 911.6(a).
FUNDING: Not Applicable.
Attachments
__,i ice D. Magdich
City Attorney
APPROVED: CCN5��
Step e -h- c wab uter, City Manager
City/CounCom/Claims/ApplicationForLateClaim-Macellari.doc
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MARK A. THIEL, SBN. 182045
LAW OFFICES OF MARK A. THIEL
3439 Brookside Road, Suite 205
Stockton, CA 95219
(209) 951-9600
Attorney for Claimant,
DANIELLE MACELLARI,
Claim of
DANIELLE MACELLARI,
against
CITY OF LODI.
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:ECEIV 9
JAN 13 2010
'11v CLEW
APPLICATION OF LEAVE
TO PRESENT LATE CLAIM
TO: CITY OF LODI:
1. Application is hereby made pursuant to Government Code, Section 911.4, for leave t(
present a late claim founded on a cause of action for injuries.
Claimant hereby alleges that on or about March 28, 2019, she was seriously injured when sht
was struck by a ladder extending out from a Union Pacific train passing through the train station or
Sacramento Street in Lodi, California. At all times mentioned herein, Claimant was standing behim
the yellow line designating the safe zone for her and the public to stand.
Lodi City Police officer Kautz appeared at the scene to perform an investigation into th(
incident. The investigation included retrieving video of the incident from the Rail Station securit;
cameras, taking statements from witnesses, and contacting Union Pacific Railroad Company. Afte
his investigation Officer Kautz gave Claimant his card an informed her the party responsible for he
injuries was Union Pacific Railroad Company.
Claimant would later have contact with a Union Pacific Railroad Company employee name(
Ton Rangel who performed his own independent investigation. After several months Mr. Range
informed Claimant that his employer was not responsible because she was standing too close to thi
train on said platform and they do not control the Rail Station or its premises.
The City of Lodi through its employee intentionally or negligently made misleading statement;
to Claimant that if she wanted to pursue a claim for her injuries she would need to contact the Unioi
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ON
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Pacific Railroad Company. The City of Lodi has further withheld the police report created by Offic
Kautz, and continues to withhold said report, which held information related to this incident. Upi
learning the City of Lodi owns and controls the rail station in question, Claimant immediately fil
a Public Claim Form with the City of Lodi on or about November 14, 2109. On December 5, 201
the City of Lodi rejected the claim and alleges the claim as not being presented within the six-111if3,
period provided by Sections 901 and 911.2 of the Government Code.
For additional circumstances relating to the cause of action, reference is made to the
' claim attached to this application.
2. The reason no claim was presented during the period of time provided by Section 911.
of the Government Code is that the claimant was under the impression the Union Pacific Rai
Company controlled and maintained the rail station in question and its adjoining platform. This
impression was created by Lodi Police Officer Kautz informing Claimant she would have to pi
a claim with Union Pacific for the incident. See Lawrence v. Slate (1985)171 Cal.App.3d 242; P(
v. City of Long Beach (1985) 172 Cal.App.3d 105. A reasonable person with Claimant's
experience and education would have relied upon Officer Kautz's statement.
3. In addition, the City of Lodi intentionally withheld from Claimant the investigati
police report related to this incident further concealing the true identity of control of the rail station.
In relying upon statements from City of Lodi employee Claimant failed to learn the true identity of the
owner of rail station until Union Pacific employee Rangel informed Claimant. See Kasalvage v. Wes
Kern County Water District (1978) 84 Cal.App.3d 529. Therefore, claimant was unable to compl:
with the requirements of the aforementioned six month statute, because of a late discovery of the c 1 a i n
and the active concealment of respondent by withholding of the critical information and refused tc
disclose to claimant.
4. Based upon mistake, inadvertence, surprise and excusable neglect Claimant failed to
the claim.timely because she relied upon Officer Kautz's statement, and her reliance was reasonabl
for a person of like intelligence and experience given the fact that the incident occurred at a 1rai
station and the ladder striking Claimant was from a Union pacific train that frequently runs throug
and stops at the same train station and rail yard.
5. Additionally, Government Code Section 901 provides claimants mandatory relief lrom
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the six-month statute when there is ongoing conduct and active concealment of wrongdoing to a
unsuspecting claimant.
6. The California Supreme Court in 1963 stated that the inflexible time limits of Govt L
claim statutes area "...trap for the unwary and ignorant claimants." Courts have regularly favored
on the merits in granting relief under Government Code §946.6.
7. Respondent was not prejudiced by this failure. The purpose of the claims statute is tc
give the public entity the opportunity to conduct a timely investigation before the claim becomes stab
and witness information or other evidence lost. In this instance, the City of Lodi's police officer
conducted an investigation that same day and was able to retrieve video footage of the incident before
it was destroyed, interview witnesses, and make conclusions of the incident, and more particularly
shown by the attached declaration of Mark A. Thiel
8. This application is being presented within a reasonable time after this cause of action
accrued, within 30 days of the rejection letter and far before one year since the incident, as snore
particularly shown by the attached declaration of Mark A. Thiel.
WHEREFORE, it is respectfully requested that this application be granted and that the .w ac lien
proposed claim be received and acted on in accordance with Section 912.4-913 of Government Code.
Dated: 1/7/ 20
Attorney for glairnant
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DECLARATION OF MARK A. THIEL
I, Mark A. Thiel, the undersigned does hereby declare:
1. I am an attorney at law duly licensed to practice such before all of the courts of the
of California.
2. I am the principal attorney in the matter of DANIELLE MACELLARI with my o f'f i cc
located at 3439 Brookside Road, Suite 205, Stockton, California.
3. Claimant has retained this office to represent her in this matter, therefore, I make i 1
declaration on claimant's behalf.
4. Sometime in late March or early April of 2019, claimant was informed by respondent'
employee, Officer Kautz that Claimant was responsible for her own injuries and if she wanted Z+
pursue a claim for this incident she needed to contact Union pacific Railroad. Claimant relied ul,oi
Officer Kautz's statement, respecting him in his authoritative capacity and his position of trust to cc!
the truth.
5. Because the injury occurred at the rail station, and a Union Pacific train ladder struck
Claimant causing injury, Claimant reasonably believed the rail station was under the control of U iii car
Pacific Railroad Company.
6. Claimant attempted on multiple occasions to obtain a copy of the police investigative
report, however, she was denied each time she requested one from the city of Lodi Police Department.
7. In good faith Claimant pursued the claim against the union pacific Railroad. It was
not until months later she was informed by Union pacific employee, Ton Rangel who that Claimam
was standing too close to the train when she was struck. Because Plaintiff was standing behind ili
designated safety line she continued to feel Union Pacific was responsible.
8. Mr. Rangel informed Claimant Union Pacific does not own or control the rail slatil 0n
in question.
9. Further investigation revealed the City of Lodi controls the rail station, and upon
receiving that information Claimant immediately thereafter filed her public claim, believing the sai lety
line must be too close to the tracks.
10. On November 12, 2019, Claimant filed her claim, some 45 days later than required h%
statute. On December 5, 2019, the City of Lodi rejected the claim as being untimely.
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11. The City of Lodi has not been prejudiced by the late filing as they have performed
investigation into to this incident which included to retrieval of video footage of the incident, witn
statements and contact with Union pacific Railroad Company employees. This same investigati
took place on the very day of the incident.
12. This office has acted with extreme diligence in filing all the necessary paperwork up
the discovery that the claim was alleged to have been presented late and a court would have no cho
under the circumstances and the applicable case law but to grant relief from this claim under the abc
circumstances should it be necessary to so petition.
I declare under the penalty of perjury under the laws of the State of California, that I
foregoing is true and correct. This declaration was executed on 7TH day of January 2020, in Stocku
California.
Attorney fXClaimant
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MARK A. THIEL, SBN. 182045
LAW OFFICES OF MARK A. THIEL
3439 Brookside Road, Suite 205
Stockton, CA 95219
(209) 951-9600
Attorney for Claimant,
DANIELLE MACELLARI,
Claim of
DANIELLE MACELLARI,
against
CITY OF LODI.
TO: CITY OF LODI:
PUBLIC CLAIM
DANIELLE MACELLARI hereby makes a claim against CITY OF LODI and make
following statements in support of the claim.
1. Notices concerning the claim should be sent to the Law Offices of Mark A. Thiel, 3439
Brookside Road, Suite 205, Stockton, California 95219,
2. The date of this action was on or about March 28, 2019.
3. The circumstances giving rise to this claim are as follows: On or about the alleged date
claimant, DANIELLE MACELLARI was standing on the platform to the Train Station located on
Sacramento Street in Lodi, California. As Claimant was walking behind the designated yellow safety
line a Union Pacific train ladder struck Claimant in the left arm and seriously caused several break:
requiring multiple surgeries thereafter.
4. At all times mentioned herein, the designated yellow safety line was and is too close
to the proximity of trains passing through and stopping in the Lodi Train Station. Thus, Claimant and
members of the public are in danger of being struck and injured such as what occurred in this incident.
Union Pacific Railroad Company has informed, and upon that Claimant relies that the City of
Lodi controls and operates the Train station in question. Claimant further alleges and herein relies or
the representations of Union Pacific that the designated yellow safety line is positioned too close tc
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the train tracks creating a safety hazard for the public.
5. Claimant has incurred medical care and treatment for her injuries. In addition,
Claimant has suffered financial damages as well as pain and suffering.
6. At all times mentioned herein the City of Lodi created a dangerous condition of puhiic
property by failing to properly and safely place the designated yellow safety line resulting in Clniirtant
being struck by the train ladder and suffering serious injury.
7. As a result of said negligence the claimant has been injured in and about her health
and emotional well being. The City of Lodi willfully, or maliciously, or negligently failed to p rfonii
their legal duty to prevent claimants' damages.
8. The names ofthe public employees causing claimant's injuries, other than those wiii ied
herein, are unknown, however, this claim will be amended to state the names of these employees.
9. The amount as of this claim to date is in excess of TEN THOUSAND DOLLARS'
($10,000.00), plus reasonable medical expenses and wage loss.
10. The basis of computation of the above is as follows:
Medical expenses incurred to date $ 143,000.00
Wage Loss $ Unknown
Expenses $ Unknown
General Damages $ 500,000.00
TOTAL $ Unknown
Plus reasonable medical expenses, estimated future medical expenses, expense, loss of kvat!os
and loss of earning capacity.
11. The appropriate court of jurisdiction would be the Superior Court of San Joagtiiii
County or Alameda County Superior Court should this claim be denied.
DATE: 11 '1 / z o
LAW OFFICES OF MA { A. THIEL
AR A. 'i4 111.
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PROOF OF SERVICE
STATF, OF CALIFORNIA COUNTY OF SAN JOAQUIN
I am a citizen of the United State and a resident of the County of San Joaquin. I am over
the age of 18 years and no party to the within above -entitled action; my business address is
3439 Brookside Road, Suite 205, Stockton CA 95219.
I am familiar with this Law Office's practice whereby the mail after being placed in a
designated area is given the appropriate postage and is deposited in the U.S. mailbox in the City
of Stockton, California after the close of the day's business.
On January 7, 2020 I served the within:
APPLICATION OF LEAVE TO PRESENT LATE CLAIM.
XXXX On all parties in said action by placing a true copy thereof enclosed in a
sealed envelope in the designated area for outgoing mail address as set
forth below:
CERTIFIED MAIL
Lodi City Hall
City Clerk
221 W. Pine Street
Lodi, CA 95240
I, MARISA GARCIA, declare under penalty of perjury under the laws of the State of
California that the foregoing is true and correct.
Executed January 7, 2020 at Stockton, California
/AR TS-A—GiPA RM"I �A
CITY COUNCIL
DOUG KUEHNE, Mayor
ALAN NAKANISHI,
Mayor Pro Tempore
MARK CHANDLER
BOBJOHNSON
JOANNE MOUNCE
December 11, 2019
CITY OF LODI
2015 "Wine Region of the Year"
CITY HALL, 221 WEST PINE STREET
P.O. BOX 3006
LODI, CALIFORNIA 95241-1910
(209) 333-6702 / FAX (209) 333-6807
www odi.gov ciivclerk0DIod_I.aov
Danielle Macelarri
2440 W. Turner Road #124
Lodi, CA 95242
STEPHEN SCHWABAUER
City Manager
JENNIFER M. FERRAIOLO
City Clerk
JANICE D. MAGDICH
City Attorney
SUBJECT: NOTICE OF LATE CLAIM - REJECTION OF CLAIM
Claimant: Danielle Macelarri
Date Claim Rec'd.: December 5, 2019
To Whom It May Concern:
The above -referenced claim, which you presented to the City Clerk's Office on
December 5, 2019, with respect to an incident occurring on March 28, 2019, is being
rejected and returned because it was not presented within six months after the event
and/or occurrence, as required by law (see Government Code Sections 901 and 911.2).
Because the claim was not presented within the time allowed by law, no action was taken
on the claim.
Your only recourse at this time is to apply without delay to the City of Lodi for leave to
present a late claim (see Government Code Sections 911.4 to 912.2, inclusive, and
Section 946.6). Under certain circumstances, leave to present a late claim may be
granted (see Government Code Section 911.6).
You may seek the advice of an attorney of your choice in connection with this matter. If
you desire to consult an attorney, you should do so immediately.
Sincerely,
rinifer erraiolo, MMC
City Clerk
cc: File
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DECLARATION OF SERVICE BY MAIL
(Code Civ Pro §1013a)
I am a citizen of the United States, over the age of 18 years, and not a party to or interested
this action. I am an employee of the City of Lodi and my business address is 221 West Pine Street,
Lodi, California 95240. On this date, December 11, 2019, I served the following document:
NO'T'ICE OF LATE CLAIM — REJECTION OF CLAIM
Danielle Macellari
® by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully
prepaid, in the United States Post Office mail at Lodi, California, addressed as set forth below.
❑ by personally delivering, or causing to be delivered a true copy thereof to the person and the
address set forth below.
❑ by causing a true copy thereof to be delivered to the party or parties at then address(es) listed
below, by and\or through the services of:
❑ Federal Express
❑ Express Mail
❑ FAX ( Followed by First Class Mail)
Danielle Macelarri
2440 W. Turner Road #124
Lodi, CA 95242
I declare under penalty of perjury that the foregoing is true and correct and this declaration
was executed at Lodi, California on December 11, 2019.
PROOF OF SERVICE
IFE9J4. FERRAIOLO
City Clerk
FILE CLAIM WITH:
City Clerk — City of Lodi
221 West Pine Street
(209) 333-6702
OR MAIL TO:
PO Box 3006
Lodi, CA 95241-1910
Government Code requires claims
`s t
Name:
Mailing Address: ! (,
City/State/Zip Code.
Name:
CLAIM FOR MONEY
OR DAMAGES AGAINST THE
CITY OF LODI, CALIFORNIA
s, gragrams,_ or witness swa
elemental sheets — clearly Id
presented by the cialmant or the
Reserved For Filing Stamp
Claim No.
COO t�-'
11C
DEC 0 5 2019
and Include the following:
CL d 1-d a
❑ Check box If same as above
Mailing Address:
Clty/State/Zip Code: Telephone: ( )
Date of Occurrence_ 3, Time of Occurrence: 3 0 an pmJ
Location: T0.9',, . L' U
Circumstances giving rise to this claim and why you believe the
L E ; ~ : h)n _ fir'? <k Yi.p
F—UJaSA, bV A tQ0,rr)rA-hP. t(?a I`1grtr,i
of Lodi is
General description of the Indebtedness, obligation, Injury, damage, or loss Incurred so far as It may be known at
the time of the presentation of the claim.
U-Q"'V\ea t't Vnp- OML(Nn.11Ile u.a C� oLA e4-oy, Ao�r),.,A . A ki miAi ri
Name of City department(s) or City employee(s) causing the Injury, damage, or loss, if known.
The amount claimed as of the date of presentation of the claim should Include the estimated amount of any
prospective Injury, damage, or loss, insofar as it may be known at the time of the presentation of the claim,
together with the basis of computation of the amount claimed.
Basis for computation of claim: Amount Claimed: $/r) on).
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), no dollar
amount shall be included in the claim. However, it shall indicate whether the claim would be a limited civil case.
A limited civil case Is one where the recovery sought, exclusive of attorney fees, Interest, and court costs does not
exceed $25,000. An unlimited civil case is one in which the recovery sought Is more than $25,000 (CCP §86.)
V Limited Civil Case 17 Unlimited Civil Case
Revised 9/2012
Set;tlan 4; .ilctditltarial 1ti#o:rrga�I�rri:
You are raq"Ired to provide thv infonr7a((on requested on theprevious pegs to comply with the California
Govarrrrnent Code; h❑waver, to assist the C!(y's ll7vestlgatlon, please 017swer the following questions;
If the claim Involves a minor, provide mlrior's data of blrth.
Name, address, and telephone number of any witnesses to the occurrence or transaction which gave rise to the
cl&IM asserted:
If the claim involves rnedicai treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment;
!f applica6fe, please attach any modlea/ bills or reports or s/m!!ar documents supporting your claim.
Toes this claim relate to an
Claimant's Auto Insurance Co.:
Mailing Address:
Clty/State/zip:
Telephone: { j
Insurance Broker/Agent:
Mailing Address;
city/5tatelzlp
relophone:
accident? ❑ No sl n below ❑Yes 11coniplete this section and sl n below)
Claimant Drivers License No.:
Se�ti.o:n 5: fUleelfcape IVle�ll'eafd, and !P E7cf;en'si-an"Aqt
License Expires;
Vehicle Make/Model/Year:
License No.;
Insurance Policy No.;
Section 911 of the"Medicare Medicaid & S -CHIP Extension Act requires the City of Lodl to report certain claims to
the federal government. Please Indicate if the claimant Is ; 66 years of age or older, or received Social Security
Disability Insurance Benefits for 24 or more months, or has End Stage Renal Disease. If yes, you may be
required to provide additonal Information to process your ciaim. Please circle one;
YES NO
'GfiEq:n 6: fV:QtI'c.e attd :$tst:h'attlre
Notice; Presentation of a false claim is a felony (Penal Code 572). Every person who, with Intent to defraud,
presents any false or fraudulent claim is punlshabfe either by pmrisonment in the county fall far a period of not
more than one year, by a fine of not exceeding one thousand dollars ($1,000), or by both such Imprisonment and
fine, or by Imprisonment In the state prison, by a fine of not exceeding ten thausand dollars {$10.000), or by both
such Imprisonment and fine. Pursuant to Code of civil Procedure §9038.
Unsigned or Incomplete claims will be returned as Insufficient, resulting In no action on the part of the City. Please note that this
Claim Form and an attachments area �ubllc record solo eat to dlecioeure under the California Public Records Act,
C1alm$ni's Name (plveserint t
J claiman's Signa ore D
Revised erzotz e Clal Submitted
Please retain a copy of the completed form for your records
CITY COUNCIL
MARK CHANDLER, Mayor
DOUG KUEHNE,
Mayor Pro Tempore
BOBJOHNSON
JOANNE MOUNCE
ALAN NAKANISHI
November 20, 2019
CITY OF LODI
2015 "Wine Region of the Year"
CITY HALL, 221 WEST PINE STREET
P.O. BOX 3006
LODI, CALIFORNIA 95241-1910
(209) 333-6702 / FAX (209) 333-6807
www.lodi.aov cltvclerk@lodi.00v
Danielle Macelarri
2440 W. Turner Road #124
Lodi, CA 95242
STEPHEN SCHWABAUER
City Manager
JENNIFER M. FERRAIOLO
City Clerk
JANICE D. MAGDICH
City Attorney
SUBJECT: NOTICE OF LATE CLAIM — REJECTION OF CLAIM
Claimant: Danielle Macelarri
Date of Claim: November 14, 2019
To Whom It May Concern:
The above -referenced claim, which you presented to the City Clerk's Office on
November 14, 2019, with respect to an incident occurring on March 28, 2019, is being
rejected and returned because it was not presented within six months after the event
and/or occurrence, as required by law (see Government Code Sections 901 and 911.2).
Because the claim was not presented within the time allowed by law, no action was taken
on the claim.
Your only recourse at this time is to apply without delay to the City o- Lodi for leave to
present a late claim (see Government Code Sections 911.4 to 912.2, inclusive, and
Section 946.6). Under certain circumstances, leave to present a late claim may be
granted (see Government Code Section 911.6).
You may seek the advice of an attorney of your choice in connection with this matter. If
you desire to consult an attorney; you should do so immediately.
Sincerely,
�erol
nifer M, MMC
Ity Clerk
cc: File
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DECLARATION OF SERVICE BY MAIL
(Code Civ Pro §1013a)
I am a citizen of the United States, over the age of 18 years, and not a party to or interested in
this action. I am an employee of the City of Lodi and my business address is 221 West Pine Street,
Lodi, California 95240. On this date, November 20, 2019, I served the following document:
NOTICE OF LATE CLAIM — REJECTION OF CLAIM
Danielle Macellari
® by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully
prepaid, in the United States Post Office mail at Lodi, California, addressed as set forth below.
❑ by personally delivering, or causing to be delivered a true copy thereof to the person and the
address set forth below.
❑ by causing a true copy thereof to be delivered to the party or parties at then address(es) listed
below, by and\or through the services of:
❑ Federal Express
❑ Express Mail
[I FAX ( Followed by First Class Mail )
Danielle Macelarri
2440 W. Turner Road #124
Lodi, CA 95242
I declare under penalty of perjury that the foregoing is true and correct and this declaration
was executed at Lodi, California on November 20, 2019.
PROOF OF SERVICE
r_ }" t
IFER F ^RRAIOL0
ity Clerk
FILE CLAIM WITH:
City Clerk — City of Lodi
22.1 West Pine Street
(209) 333-6702
OR MAIL TO:
PO Box 3006
Lodi, CA 95241-1910
CLAIM FOR MONEY
OR DAMAGES AGAINST THE
CITY OF LODI, CALIFORNIA
Reserved For Flling Stamp
Claim No, �Q—gyp
EECE11EN
Nov 14 2019
MY CLER
Attach estImates recel is hotos dle ams or w! ness statements to sy0ort VQt1r claim. if add/ to space
Is needed, attach 2MR1emenfal s eets — clearly, ldentifv the sectlon(s1 belnq answered
Government Code requires claims be presented by the claimant or the claimant's representative and include the following:
Name: 1�
Address: '
ftlZlo Code:
Name:
Mailing Address:
City/State/Zip Code:
DU
2 Telephone:
❑ Check box If same as above
e: (
Date of Occurrence: _ c) 1 q Time of Occurrence: 0 am pm
Location: ; o
Circumstances giving rise to this claim and why you believe the City of Lodi is responsible:
General description of the indebtedness, obligation, Injury, damage, or loss incurred so far as It may be known at
the time of the presentation of the claim.
2Xr A,\ Civ,
Name of City department(s) or City employee(s) causing the Injury, damage, or loss, if known.
The amount claimed as of the date of presentation of the claim should include the estimated amount of any
prospective Injury, damage, or loss, insofar as It may be known at the time of the presentation of the claim,
together with the basis of computation of the amount claimed.
Basis for computation of claim: Amount Claimed: $
Lk,.k, c! Y
�V�S -� L] h+�{ ►r w► aM IL m A C t . c ►J�-
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), no dollar
amount shall be Included In the claim. However, it shall indicate whether the claim would be a limited civil case,
A limited civil case Is one where the recovery sought, exclusive of attorney fees, Interest, and court costs does not
exceed $25,000, An unlimited civil case is one In which the recovery sought Is more than $25,000 (CCP §86,)
Limited Civil Case F- �, Unlimited Civil Case
Revised 912012
Section ,4; A.dd:ttl�nal, l:n%:rmatl:or .;
You are required to provide the information requested oft tite prevlous page to comply with the Callfornia
GovamMent Code; however, to asslst the Clty's Investlga(lon, please answer the following questions;
IIIf the claim involves a minor, provide mlhor'b date of birth.
Name, address, and telephone number of any witnesses to the occurrence or transaction which gave rise to the
claim asserted:
If the claim Involves medical treatment for n claimed Injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment:
if applicable, please attach any rrredical bills or reports or similar doeurnonfs supporting your claim.
]nes this claim relate to an automo.bfle accldent7 ❑ No sign below)Claimant's Auto Insurance Cb,; ❑Yes I com late this section and 0 Ig n balaw)
Halling Address:
Claimant Drivers License No.:
�
Cltylstatalzlp;
License Expires:
Telephone; ( ) Vehicle Make/Model/Year:
Insurance Broker/Agent;
Mailing Address:
License No.:
GIEylStatelZlp
Telephone: { y
Insurance Policy No,:
Seda'n's: N(e,ellcare IVledl'caId,and•S-G:F{I:R 124'enslon_Art
Section 111 of the.Medlcare Medlcald & S -CHIP Extension Act requires the City of Lod to ren rnrlaln rW _ +-
the federal government, Please 1, I #e if tl,� ni�r�,,,,� :_ . _ �s„ ., .,:uai yr �ecelvec oclai Securkt
o4is tur more months, or has End Stage Renal Disease, if yes, you may be y
required to provide additonef Information to process your claim, Please circle one;
YES NO
8; N'Qtic,e
Notice: Presentation of a false claim Is a felony (Penal Code §72), Every person who, with intent to defraud,
presents any false or fraudulent claim Is punishable elther by,pinrlsonment In the county Jai[ for a period of not
more than one year, by a flne of riot exceeding one thousand dollars ($1,000), or by both such Imprisonment and
fine, or by Imprisonment In the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both
such Imprisonment and firle. PurSuent to Code of Civil Procedure §1038.
Unsigned or Incomplete claims will be returned as Insufficient, resulting In no action on the part of the City. Please note that this
Claim Fornt and a my attach me"is are a ubllc. record sub Oct to disclosure under the California Public Records Act.
-._....»••- iatlar� r►rarJ Clalmani'551 n tura'
Revised 9/2012 Date Claim Submltteci
Please retain a copy of the completed form for your records