Preview
EYome iit) Plaintiff's Claim and ORDER Coa dines dite hare whan hacer ie ed.
to Go to Small Claims Court
LL CLAIMS
Notice to the person being sued: SMA L
* You are the defendant if your name is listed in (2) on page 2 of this form. San Francisco County Superior Court
The person suing you is the plaintiff, listed in (1) on page 2. ;
* You and the plaintiff must go to court on the trial date listed below. If you AUG 28 2020
do not go to court, you may lose the case.
If you lose, the court can order that your wages, money, or property be
taken to pay this claim. BY:
F THE COURT
CLERK
Deputy Clerk
Bring witnesses, receipts, and any evidence you need to prove your case. Fill in court name and street address:
Read this form and all pages attached to understand the claim against you Superior Court of California, County of
and to protect your rights. SMALL CLAIMS
SUP,
Aviso al Demandado: 7400 Meal ape COUR ns
Usted es el Demandado si su nombre figura en (2) de la pagina 2 de este FRANCISCO, CALIFORNIA 94102
formulario. La persona que lo demanda es el Demandante, la que figura en
@ de la pagina 2. Court fils in case number when form is filed.
Usted y el Demandante tienen que presentarse en la corte en la fecha del nue"
juicio indicada a continuaci6n. Si no se presenta, puede perder el caso. 2 0 8 63 5 7 8
Si pierde el caso la corte podria ordenar que le quiten de su sueldo, dinerou |Case Name:
otros bienes para pagar este reclamo.
Lleve testigos, recibos y cualquier otra prueba que necesite para probar su juow O VS: CCS
caso.
Lea este formulario y todas las paginas adjuntas para entender la demanda en su contra y para proteger sus derechos.
(olgel-1ah Com CTom com erolU ing
The people in (4) and @) must go to court: (Clerk fills out section below.)
on
>
Date | 1-!! _S5Oe Sz Foor
2.
3.
Date: WEIS A Clerk, by QD Fete
Instructions for the person suing:
You are the plaintiff. The person you are suing is the defendant.
Before you fill out this form, read form SC-100-INFO, Jnformation for the Plaintiff, to know your rights. Get
SC-100-INFO at any courthouse or county law library, or go to www.courts.ca.gov/smallclaims/forms.
\> Dat Time Department Name and address of court, if different from above
Trial
ie fro | 2Spa
T_T t
» Deputy
Fill out pages 2 and 3 of this form. Then make copies of all pages of this form. (Make one copy for each party named in
this case and an extra copy for yourself.) Take or mail the original and these copies to the court clerk’s office and pay
the filing fee. The clerk will write the date of your trial in the box above.
You must have someone at least 18—not you or anyone else listed in this case—give each defendant a court-stamped
copy of all five pages of this form and any pages this form tells you to attach. There are special rules for “serving,” or
delivering, this form to public entities, associations, and some businesses. See forms SC-104, SC-104B, and SC-104C.
Go to court on your trial date listed above. Bring witnesses, receipts, and any evidence you need to prove your case.
‘ul Canal of Calta cate o \ Plaintiff's Claim and ORDER SONS, Page 1086
Cadet ext rsa, gg 1t610cea, to Go to Small Claims Court >
(Small Claims)Plaintiff (list names): Case Number:
Jordan Wood
@ The plaintiff (the person, business, or public entity that is suing) is:
Name: Jordan Wood Phone: (415) 802-3288
Street address: 1530F Pershing Dr, San Francisco CA 94129
Street City State Zip
Mailing address (if different):
Street City State Zip
If more than one plaintiff, list next plaintiff here:
Name: Phone:
Street address:
Street City State Zip
Mailing address (if different):
Street City State Zip
©) Check here if more than two plaintiffs and attach form SC-100A.
0) Check here if either plaintiff listed above is doing business under a fictitious name. If so, attach form SC-103.
0) Check here if any plaintiff is a “licensee” or “deferred deposit originator” (payday lender) under Financial
Code sections 23000 et seq.
@ The defendant(the person, business, or public entity being sued) is:
Namie: City And County Of San Francisco Phone:
Street address: 1390 Market St San Francisco CA 94102
Street City State Zip
Mailing address (if different):
Street City State Zip
If the defendant is a corporation, limited liability company, or public entity, list the person
or agent authorized for service of process here:
Name: Marlena Green Job title, if known: _Case Manager
Address: _ 1390 Market Street Floor 7 - Claims Division San Francisco Ca 94102
Street City State Zip
© Check here if your case is against more than one defendant, and attach form SC-100A.
© Check here if any defendant is on active military duty, and write his or her name here:
® The plaintiff claims the defendant owes $ 1500 . (Explain below):
a. Why does the defendant owe the pint money?
Motorcycle accident caused ‘by over painted "Stop" eee ona city, road! “Paint had no iraction’ on
downhill stop.
When did this Teonen? (Date): 01/04/2020
b. Ifno specific date, give the time period: Date started: Through:
c. How did you calculate the money) owed to you? (Pein not include court costs or fees for service.)
rt
Parts to replace damage done to the motorcycle.
OO Check here if you need more space. Attach one sheet of paper or form MC-031 and write “SC-100, Item 3” at
the top.
Reomees omeaty Tea: Plaintiff's Claim and ORDER to Go to Small Claims Court SC-100, Page 2 of 5
(Small Claims) —>Plaintiff (list names): Case Number:
Tanya Pulido
(@) You must ask the defendant (in person, in writing, or by phone) to pay you before you
sue. If your claim is for possession of property, you must ask the defendant to give you
the property. Have you done this?
fl Yes [No If no, explain why not:
Claim number 20-01563
® Why are you filing your claim at this courthouse?
This courthouse covers the area (check the one that applies):
+a. Ed (1) Where the defendant lives or does business. (4) Where a contract (written or spoken) was made,
(2) Where the plaintiff's property was damaged. signed, performed, or broken by the defendant or
(3) Where the plaintiff was injured. where the defendant lived or did business when the
defendant made the contract.
b. £1 Where the buyer or lessee signed the contract, lives now, or lived when the contract was made, if this claim,
is about an offer or contract for personal, family, or household goods, services, or loans. (Code Civ. Proc.,
§ 395(b).)
c. [1 Where the buyer signed the contract, lives now, or lived when the contract was made, if this claim is about a
retail installment contract (like a credit card). (Civ Code, § 1812.10.)
d. 1) Where the buyer signed the contract, lives now, or lived when the contract was made, or where the vehicle is
permanently garaged, if this claim is about a vehicle finance sale. (Civ Code, § 2984.4.)
e. [) Other (specify):
© List the zip code of the place checked in © above (i/you know): 94102
® Is your claim about an attorney-client fee dispute? [] Yes [x] No
If yes, and if you have had arbitration, fill out form SC-101, attach it to this form, and check here: (]
@ Are you suing a public entity? Gi Yes [1 No
If yes, you must file a written claim with the entity first. [] A claim was filed on (date):
If the public entity denies your claim or does not answer within the time allowed by law, you can file this form.
@ Have you filed more than 12 other small claims within the last 12 months in California?
Yes [kK] No Jfyes, the filing fee for this case will be higher.
(10) Is your claim for more than $2,500? [] Yes [J No
If yes, I have not filed, and understand that I cannot file, more than two small claims cases for more than $2,500 in
California during this calendar year.
| understand that by filing a claim in small claims court, | have no right to appeal this
claim.
I declare, under penalty of perjury under California State law, that the information above and on any attachments to this
form is true and correct. VU LJ
Date: 08/13/20 Jordan Wood > LL
Plaintiff types or prints name here LZ Plaintiff signs here
Date:
Second plaintiff types or prints name here Second plaintiff signs here
Requests for Accommodations
[Assistive listening systems, computer-assisted real-time captioning, or sign language interpreter
services are available if you ask at least five days before the trial. Contact the clerk’s office for form
IMC-410, Request for Accommodations by Persons With Disabilities and Response. (Civ. Code, § 54.8.)
——— Plaintiff's Claim and ORDER to Go to Small Claims Court SC-100, Page “s
(Small Claims)yoru Tt]t) Informacién para el demandado (la persona demandada)
La “Corte de reclamos menores” es una corte especial donde se
deciden casos por $10,000 o menos. Los individuos, o sea las
“personas fisicas” y los propietarios por cuenta propia, pueden
reclamar hasta $10,000. Las corporaciones, asociaciones, entidades
publicas y otras empresas solo pueden reciamar hasta $5,000. (Vea
abajo para las excepciones.*) El proceso es rapido y barato. Las
reglas son sencillas e informales. Usted es el Demandado—a
persona que se esta demandando. La persona que lo esta
demandando es el Demandante.
Necesito un abogado? Puede hablar con un abogado antes o
después del caso. Pero no puede tener a un abogado que lo
represente ante la corte (a menos que se trate de una apelacién de un
caso de reclamos menores).
zCémo me preparo para ir a la corte? No tiene que presentar
ningunos papeles antes del juicio, a menos que piense que ésta es la
corte equivocada para su caso. Pero lieve al juicio cualquier testigos,
recibos y pruebas que apoyan su caso. Y lea “Esté preparado para su
juicio” en www.courts.ca.gov/reclamosmenores/preparese.
Qué hago si necesito una adaptacién? Si tiene una discapacidad
0 tiene impedimentos de audicién, llene el formulario MC-410,
Request for Accomodations. Entregue el formulario al secretario de la
corte o al Coordinador de Acceso/ADA de su corte.
2Qué pasa si no hablo bien inglés? Pregintele al secretario de la
corte lo mas pronto posible si en el juzgado habré un intérprete
disponible y cémo solicitarlo. No siempre estan disponibles los
intérpretes de la corte. Otra opcién es llevar a un adulto que pueda
interpretar para usted siempre que esa persona no sea un testigo ni
un abogado. O puede pedir a la corte una lista de intérpretes
particulares disponibles para contratar.
~zDénde puedo obtener los formularios de la corte que necesito?
Vaya a cualquier edificio de la corte, la biblioteca legal de su condado,
0 imprima los formularios en www.courts.ca.gov/ smaliciaims/forms
(pagina esta en inglés).
zQué pasa en el juicio? El juez escuchara a ambas partes. El juez
puede tomar su decisién durante la audiencia o enviarsela por correo
después.
Qué pasa si pierdo el caso? Si pierde, puede apelar. Tendré que
pagar una cuota. (El Demandante no puede apelar su propio reciamo.)
+ Si estuvo presente en el juicio, Ilene el formulario SC-140, Aviso de
apelaci6n (Notice of Appeal). Tiene que presentarlo dentro de 30
dias después de que el secretario le entregue o envie la decision
(fallo) del juez en el formulario SC-200 o SC-130, Aviso de
publicacién del fallo (Notice of Entry of Judgment).
Si no estuvo en el juicio, llene y presente el formulario SC-135,
Aviso de peticion para anular él fallo y Declaraci6n para pedirle al
juez que anule el fallo (decisi6n). Si la corte no le otorga un nuevo
juicio, tiene 10 dias para apelar la decision. Presente el formulario
SC-140.
Para obtener mas informacién sobre las apelaciones, vea www.
courts.ca.gov/reclamosmenores/apelaciones.
Tengo otras opciones? Si. Si lo estén demandando, puede:
. Resolver su caso antes del juicio. Si usted y el Demandante se
ponen de acuerdo en cémo resolver el caso, el Demandante tiene
que presentar el formulario CIV-110, Solicitud de desestimacién
(Request for Dismissal) ante el secretario de la corte. Pidale al
Asesor de Reclamos Menores que lo ayude.
« Probar que es la corte equivocada. Envie una carta a la corte
antes del juicio explicando por qué cree que es la corte
equivocada. Pidale a la corte que despida el reciamo.Tiene que
entregar (dar) una copia de su carta (por correo o en persona) a
todas las partes. (Su carta a la corte tiene que decir que hizo la
entrega.)
Ir al juicio y tratar de ganar el caso. Lieve testigos, recibos y
cualquier prueba que necesite para probar su caso. Si desea que
la corte emita una orden de comparecencia para que los testigos
vayan al juicio, llene el formulario SC-107, Citatorio de reclamos
menores (Small Claims Subpoena) y entrégueselo legaimente al
testigo.
. Demandar a la persona que lo demand6. Si tiene un reclamo
contra el Demandante, y el reclamo se puede presentar en la
corte de reclamos menores, tal como se describe en este
formulario, puede presentar el formulario SC-120, Reclamo del
demandado (Defendant's Claim) y presentarlo en este mismo
caso. Si su reclamo excede el limite permitido en la corte de
reclamos menores, puede igualmente presentarlo en la corte de
reclamos menores si esta dispuesto a limitar su reciamo al
maximo permitido, o puede presentar un reclamo por el monto
total en la corte apropiada. Si su reclamo excede el limite
permitido en la corte de reclamos menores y esta relacionado con
el mismo contrato, transaccién, asunto o acontecimiento que el
reclamo del Demandante, puede presentar su reciamo en la corte
apropiada y presentar una mocién para transferir el reciamo del
Demandante a dicha corte, para poder resolver los dos reclamos
juntos. Puede ver una descripcién de los montos permitidos en el
parrafo anterior titulado “Corte de reclamos menores”.
. Aeptar el reclamo del Demandante y pagar el dinero. O, sino
puede pagar en ese momento, vaya al juicio y diga que quiere
hacer los pagos.
No ir al juicio y aceptar el fallo por falta de comparecencia. Si
no llega a un acuerdo con el Demandante y no va al juicio (fallo
por falta de comparecencia), el juez le puede otorgar al
Demandante lo que esta reclamando mas los costos de la corte.
En ese caso, el Demandante legalmente puede tomar su dinero,
‘su sueldo o sus bienes para cobrar el fallo.
Qué hago si necesito mas tiempo? Puede cambiar la fecha del
juicio si:
* No puede ir a la corte en la fecha programada (tendré que pagar
una cuota para aplazar el juicio), o
+ Nole entregaron los documentos legalmente (no recibié la orden
para ir a la corte) por lo menos 15 dias antes del juicio (6 20 dias
si vive fuera del condado), o
* Necesita mas tiempo para conseguir intérprete. (Se permite un
solo aplazamiento sin tener que pagar cuota para aplazar el
juicio).
Preguntele al secretario de reclamos menores sobre las reglas y las
cuotas para aplazar un juicio. O lene el formulario SC-150 (0 escriba
una carta) y envielo antes del plazo a la corte y a todas las otras.
personas que figuran en sus papeles de la corte. Adjunte un cheque
para pagar los costos de la corte, a menos que le hayan dado una
exencién.
Necesita ayuda? El Asesor de Reclamos Menores de su
‘condado le puede ayudar sin cargo.
_
O visite www.courts.ca.gov/reclamosmenores/asesores.
limites en un ‘contra un
(Vea el Cédigo de Pro civ,
116.220 (c).)
Revised January 1, 2017
Reclamo del Demandante y ORDEN
‘SC-100, Page 5 of 5
Para Ir a la Corte de Reclamos Menores
(Reclamos Menores)
For your protection and privacy, please press the Clear
This Form button after you have printed the form.
(ERAT [Seve tie form] =a tor]Sera TtT¢) Information for the defendant (the person being sued)
“Small claims court" is a special court where claims for
$10,000 or less are decided. Individuals, including "natural
persons" and sole proprietors, may claim up to $10,000.
Corporations, partnerships, public entities, and other businesses
are limited to claims of $5,000. (See below for exceptions.*) The
process is quick and cheap. The rules are simple and informal.
You are the defendant—the person being sued. The person who is
‘suing you is the plaintiff.
Do I need a lawyer? You may talk to a lawyer before or after
the case. But you may not have a lawyer represent you in court
(unless this is an appeal from a small claims case).
How do | get ready for court? You don't have to file any
papers before your trial, unless you think this is the wrong court
for your case. But bring to your trial any witnesses, receipts, and
evidence that supports your case. And read “Be Prepared for Your
Trial” at www.courts.ca.gov/smaliclaims/prepare.
What if | need an accommodation? If you have a
disability or are hearing impaired, fill out form MC-410, Request for
Accommodations. Give the form to your court clerk or the ADA/
Access Coordinator.
What if | don’t speak English well? Ask the court clerk
as soon as possible if your court has a court-provided interpreter
available and how to request one. A court-provided interpreter may
not be available. Alternatively, you may bring an adult who is not a
witness or an attorney to interpret for you or ask the court for a list
of interpreters for hire.
Where can | get the court forms | need? Go to any
courthouse or your county law library, or print forms at www.
courts.ca.gov/smaliclaims/forms.
What happens at the trial? The judge will listen to both
sides. The judge may make a decision at your trial or mail the
decision to you later.
What if I lose the case? If you lose, you may appeal. You'll
have to pay a fee. (Plaintiffs cannot appeal their own claims.)
« If you were at the trial, file form SC-140, Notice of Appeal. You
must file within 30 days after the clerk hands or mails you the
judge's decision (judgment) on form SC-200 or form SC-130,
Notice of Entry of Judgment.
« If you were nof at the trial, fill out and file form SC-135, Notice of
Motion to Vacate Judgment and Declaration, to ask the judge to
cancel the judgment (decision). If the judge does not give you a
new trial, you have 10 days to appeal the decision. File form
SC-140.
For more information on appeals, see www.courts.ca.gov/
smaliclaims/appeals.
Do | have options?
Yes. If you are being sued, you can:
+ Settle your case before the trial. If you and the
plaintiff agree on how to settle the case, the plaintiff must file
form CIV-110, Request for Dismissal, with the clerk. Ask the
‘Small Claims Advisor for help.
+ Prove this is the wrong court. Send a letter to the court
before your trial explaining why you think this is the wrong court.
Ask the court to dismiss the claim. You must serve (give) a copy
of your letter (by mail or in person) to all parties. (Your letter to
the court must say you have done so.)
+ Go to the trial and try to win your case. Bring
witnesses, receipts, and any evidence you need to prove your
case. To have the court order a witness to go to the trial, fill out
form SC-107 (Small Claims Subpoena) and have it served on
the witness.
Sue the person who is suing you. If you have a claim
against the plaintiff, and the claim is appropriate for small claims
court as described on this form, you may file Defendant's Claim
(form SC-120) and bring the claim in this action. If your claim is
for more than allowed in small claims court, you may still file it in
‘small claims court if you give up the amount over the small
claims value amount, or you may file a claim for the full value of
the claim in the appropriate court. If your claim is for more than
allowed in small claims court and relates to the same contract,
transaction, matter, or event that is the subject of the plaintiff's
claim, you may file your claim in the appropriate court and file a
motion to transfer the plaintiff's 's claim to that court to resolve
both matters together. You can see a description of the amounts
allowed in the paragraph above titled “Small Claims Court.”
+ Agree with the plaintiff's claim and pay the
money. Or, if you can't pay the money now, go to your trial
and say you want to make payments.
- Let the case "default." If you don't settle and do not go to
the trial (default), the judge may give the plaintiff what he or she
is asking for plus court costs. If this happens, the plaintiff can
legally take your money, wages, and property to pay the
judgment.
What if | need more time?
You can change the trial date if:
+ You cannot go to court on the scheduled date (you will have to
pay a fee to postpone the trial), or
You did not get served (receive this order to go to court) at least
15 days before the trial (or 20 days if you live outside the
county), or
+ You need more time to get an interpreter. One postponement is
allowed, and you will not have to pay a fee to delay the trial.
Ask the Small Claims Clerk about the rules and fees for
postponing a trial. Or fill out form SC-150 (or write a letter) and
mail it to the court and to all other people listed on your court
papers before the deadline. Enclose a check for your court fees,
unless a fee waiver was granted.
Need help?
Your county's Small Claims Advisor can help for free.
T “1
_t
Or go to www.courts.ca.gov/smaliciaims/advisor.
* Exceptions: Different limits apply in an action against a defendant who is a guarantor. (See Code Civ. Proc., § 116.220(c).)
Revised January 1, 2017
Plaintiff's Claim and ORDER to Go to Small Claims Court
(Small Claims)
SC-100, Page 4 of 5
=City AND COUNTY of An FRANCISCO Orice OF THE City ATTORNEY
Marleena Green
Claims Adjuster
DiRECTDIAL: (418) 554-4203
E-MAIL: MARLEENA.GREEN@SFCITYATTY.ORG
. March 6, 2020
Jordan Wood
1530F Pershing Dr.
San Francisco, CA 94129
RE: Claim of Jordan Wood / Claim Number 20-01563
Department: MTASTRTS Pedestrian, Bicycle & Traffic Engineering
Incident Date: January 4, 2020
Claim Filed: January 17, 2020
NOTICE OF ACTION UPON CLAIM . PLEASE TAKE NOTICE THAT
An investigation of your claim filed with the City and County of San Francisco has revealed no indication
of liability on the part of the City and County. Accordingly, your claim is DENIED.
WARNING
Subject to certain exceptions, you have only six (6) months from the date this notice was personally
delivered or deposited in the mail to file a court action on this claim. See Government Code section
945.6. This time limitation applies only to causes of action arising under California law for which a claim
is mandated by the California Government Claims Act, Government Code sections 900 et. seq. Other
causes of action, including those arising under federal law, may have shorter time limitations for filing.
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.
Please also be advised that, pursuant to Code of Civil Procedure sections 128.7 and 1038, the City and
County of San Francisco will seek to recover all costs of defense in the event an action is filed in this
matter and it is determined that the action was not brought in good faith and with reasonable cause.
Very truly yours,
DENNIS J. HERRERA
City Attorney
Helin Gley
Marleena Green
Claims Adjuster
Fox PLAZA - 1390 MARKET STREET, 7TH FLOOR- SAN FRANCISCO, CAUFORNIA 94102-5408
RECEPTION: (415) 554-3900. FACSIMILE: (415) 554-8795
1n:\claim\cl2020\20-01563\01433818.docxClaim of: Jordan Wood Claim Filed: January 17, 2020
I, Marleena Green, say: I am a citizen of the United States, over eighteen years of age,
and not a party to the within action; that I am employed by the City Attorney's Office of San
Francisco, Fox Plaza, 1390 Market Street, 7th Floor, San Francisco, CA 94102.
That on March 6, 2020 I served:
NOTICE OF ACTION UPON CLAIM
by placing a true copy thereof in an envelope addressed to:
Jordan Wood
1530F Pershing Dr.
San Francisco, CA 94129
Following ordinary business practices, I sealed true and correct copies of the above
documents in addressed envelope(s) and placed them at my workplace for collection and mailing
with the United States Postal Service. I am readily familiar with the practices of the San
Francisco City Attorney's Office for collecting and processing mail. In the ordinary course of
business, the sealed envelope(s) that I placed for collection would be deposited, postage prepaid,
with the United States Postal Service that same day.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on March 6, 2020 at San Francisco, California.
Hatt... Gut,
Marleena Green
DECLARATION OF SERVICE BY MAIL
n:\claim\cl2020\20-01563\01433816.docx.CLAIM AGAINST THE CITY AND COUNTY OF SAN FRANCISCO
Before completing this form please read the instructions on the back. Untimely claims will be returned. Please submit
this form and supporting documentation to the Controller’s Office, Claims Division, 1390 Market Street, 7" Floor,
San Francisco, CA 94102 in person or by mail.
*=REQUIRED ** = REQUIRED IF KNOWN
1. Claimant’s Name and Home Address (Please Print Clearly)
* Jordan Wood
2. Send Official Notices and Correspondence to:
*
1530F Pershing Dr
1530F Pershing Dr
City San Francisco Stateca_ Zip 94129 city San Francisco State Zip 94129
Telephone Evening (418) 802-3288 _| | Telephone °™*™* — (415) 802-3288
3. Date of Birth 4. Social Security Number 5. Date of Incident [6. Time of Incident (as or pm
08/06/1978 100-86-6782 * 01/04/2020 [** 2:20 AM
7. Location of Incident or Accident
“* Laurel St. intersection of Washtington St.
8. Claimant Vehicle License Plate #, Type, Mileage, and Year
™ 4853030
9. Basis of Claim. State in detail all facts and circumstances of the incident. Identify all persons, entities, property and City
departments involved. State why you believe the City is responsible for the alleged injury, property damage or loss.
* Applied the brakes to come to stop at a downhill stop sign on the letter "S" going 3 mph. Front tire
slipped on letter the motocycle flipped over. Paint on the letter "S" was very thick and had no grip
Was light moisture on the letter from dew. | called 911 and decided to go to police station after |
returned home and picked up my car to drive myself there.
bee of City Employee who allegedly caused injury or loss
Name, |.D. Number and City Department Type of City Vehicle
Vehicle License Number and Bus or Train Number
bee
10. Description of Claimant's injury, property damage or loss
* Injuries
documentation.
Swollen wrist, shoulder, and stiff neck for a week.
Still having wrist nerve pain on 01/17/20
___ ITEMS
+ Engine Cover,
11, Amount of Claimant's property damage or loss and
method of computation. Attach supporting
(See Instructions)
lever, $ 134.00
Fairing replacement $ 498.00
Barend, sliders,
mirror,peg $ 256.00
Motorcycle damage - paint, frame sliders, bar ends,
shifter, foot peg, engine cover.
Personal safety equipment (i.e helmet, boots)
Boots, Helmet $ 429.00
TOTAL AMOUNT $1,317.00 __
Court Jurisdiction: Limited (up to $25,000)
Unlimited (over $25,000) []
CRIMINAL PENALTY FOR PRESENTING A FALSE OR
FRAUDULENT CLAIM IS IMPRISONMENT OR FINE OR BOTH.
(PENAL CODE §72)
12. Witnesses (if any) Name Address Telephone
4.
2.
13. Do Not Write In This Space
*
Signature of Claimant or Representative Date
Print Name Relationship to
Claimant
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EYome iit) Plaintiff's Claim and ORDER Coa dines dite hare whan hacer ie ed. to Go to Small Claims Court LL CLAIMS Notice to the person being sued: SMA L * You are the defendant if your name is listed in (2) on page 2 of this form. San Francisco County Superior Court The person suing you is the plaintiff, listed in (1) on page 2. ; * You and the plaintiff must go to court on the trial date listed below. If you AUG 28 2020 do not go to court, you may lose the case. If you lose, the court can order that your wages, money, or property be taken to pay this claim. BY: F THE COURT CLERK Deputy Clerk Bring witnesses, receipts, and any evidence you need to prove your case. Fill in court name and street address: Read this form and all pages attached to understand the claim against you Superior Court of California, County of and to protect your rights. SMALL CLAIMS SUP, Aviso al Demandado: 7400 Meal ape COUR ns Usted es el Demandado si su nombre figura en (2) de la pagina 2 de este FRANCISCO, CALIFORNIA 94102 formulario. La persona que lo demanda es el Demandante, la que figura en @ de la pagina 2. Court fils in case number when form is filed. Usted y el Demandante tienen que presentarse en la corte en la fecha del nue" juicio indicada a continuaci6n. Si no se presenta, puede perder el caso. 2 0 8 63 5 7 8 Si pierde el caso la corte podria ordenar que le quiten de su sueldo, dinerou |Case Name: otros bienes para pagar este reclamo. Lleve testigos, recibos y cualquier otra prueba que necesite para probar su juow O VS: CCS caso. Lea este formulario y todas las paginas adjuntas para entender la demanda en su contra y para proteger sus derechos. (olgel-1ah Com CTom com erolU ing The people in (4) and @) must go to court: (Clerk fills out section below.) on > Date | 1-!! _S5Oe Sz Foor 2. 3. Date: WEIS A Clerk, by QD Fete Instructions for the person suing: You are the plaintiff. The person you are suing is the defendant. Before you fill out this form, read form SC-100-INFO, Jnformation for the Plaintiff, to know your rights. Get SC-100-INFO at any courthouse or county law library, or go to www.courts.ca.gov/smallclaims/forms. \> Dat Time Department Name and address of court, if different from above Trial ie fro | 2Spa T_T t » Deputy Fill out pages 2 and 3 of this form. Then make copies of all pages of this form. (Make one copy for each party named in this case and an extra copy for yourself.) Take or mail the original and these copies to the court clerk’s office and pay the filing fee. The clerk will write the date of your trial in the box above. You must have someone at least 18—not you or anyone else listed in this case—give each defendant a court-stamped copy of all five pages of this form and any pages this form tells you to attach. There are special rules for “serving,” or delivering, this form to public entities, associations, and some businesses. See forms SC-104, SC-104B, and SC-104C. Go to court on your trial date listed above. Bring witnesses, receipts, and any evidence you need to prove your case. ‘ul Canal of Calta cate o \ Plaintiff's Claim and ORDER SONS, Page 1086 Cadet ext rsa, gg 1t610cea, to Go to Small Claims Court > (Small Claims)Plaintiff (list names): Case Number: Jordan Wood @ The plaintiff (the person, business, or public entity that is suing) is: Name: Jordan Wood Phone: (415) 802-3288 Street address: 1530F Pershing Dr, San Francisco CA 94129 Street City State Zip Mailing address (if different): Street City State Zip If more than one plaintiff, list next plaintiff here: Name: Phone: Street address: Street City State Zip Mailing address (if different): Street City State Zip ©) Check here if more than two plaintiffs and attach form SC-100A. 0) Check here if either plaintiff listed above is doing business under a fictitious name. If so, attach form SC-103. 0) Check here if any plaintiff is a “licensee” or “deferred deposit originator” (payday lender) under Financial Code sections 23000 et seq. @ The defendant(the person, business, or public entity being sued) is: Namie: City And County Of San Francisco Phone: Street address: 1390 Market St San Francisco CA 94102 Street City State Zip Mailing address (if different): Street City State Zip If the defendant is a corporation, limited liability company, or public entity, list the person or agent authorized for service of process here: Name: Marlena Green Job title, if known: _Case Manager Address: _ 1390 Market Street Floor 7 - Claims Division San Francisco Ca 94102 Street City State Zip © Check here if your case is against more than one defendant, and attach form SC-100A. © Check here if any defendant is on active military duty, and write his or her name here: ® The plaintiff claims the defendant owes $ 1500 . (Explain below): a. Why does the defendant owe the pint money? Motorcycle accident caused ‘by over painted "Stop" eee ona city, road! “Paint had no iraction’ on downhill stop. When did this Teonen? (Date): 01/04/2020 b. Ifno specific date, give the time period: Date started: Through: c. How did you calculate the money) owed to you? (Pein not include court costs or fees for service.) rt Parts to replace damage done to the motorcycle. OO Check here if you need more space. Attach one sheet of paper or form MC-031 and write “SC-100, Item 3” at the top. Reomees omeaty Tea: Plaintiff's Claim and ORDER to Go to Small Claims Court SC-100, Page 2 of 5 (Small Claims) —>Plaintiff (list names): Case Number: Tanya Pulido (@) You must ask the defendant (in person, in writing, or by phone) to pay you before you sue. If your claim is for possession of property, you must ask the defendant to give you the property. Have you done this? fl Yes [No If no, explain why not: Claim number 20-01563 ® Why are you filing your claim at this courthouse? This courthouse covers the area (check the one that applies): +a. Ed (1) Where the defendant lives or does business. (4) Where a contract (written or spoken) was made, (2) Where the plaintiff's property was damaged. signed, performed, or broken by the defendant or (3) Where the plaintiff was injured. where the defendant lived or did business when the defendant made the contract. b. £1 Where the buyer or lessee signed the contract, lives now, or lived when the contract was made, if this claim, is about an offer or contract for personal, family, or household goods, services, or loans. (Code Civ. Proc., § 395(b).) c. [1 Where the buyer signed the contract, lives now, or lived when the contract was made, if this claim is about a retail installment contract (like a credit card). (Civ Code, § 1812.10.) d. 1) Where the buyer signed the contract, lives now, or lived when the contract was made, or where the vehicle is permanently garaged, if this claim is about a vehicle finance sale. (Civ Code, § 2984.4.) e. [) Other (specify): © List the zip code of the place checked in © above (i/you know): 94102 ® Is your claim about an attorney-client fee dispute? [] Yes [x] No If yes, and if you have had arbitration, fill out form SC-101, attach it to this form, and check here: (] @ Are you suing a public entity? Gi Yes [1 No If yes, you must file a written claim with the entity first. [] A claim was filed on (date): If the public entity denies your claim or does not answer within the time allowed by law, you can file this form. @ Have you filed more than 12 other small claims within the last 12 months in California? Yes [kK] No Jfyes, the filing fee for this case will be higher. (10) Is your claim for more than $2,500? [] Yes [J No If yes, I have not filed, and understand that I cannot file, more than two small claims cases for more than $2,500 in California during this calendar year. | understand that by filing a claim in small claims court, | have no right to appeal this claim. I declare, under penalty of perjury under California State law, that the information above and on any attachments to this form is true and correct. VU LJ Date: 08/13/20 Jordan Wood > LL Plaintiff types or prints name here LZ Plaintiff signs here Date: Second plaintiff types or prints name here Second plaintiff signs here Requests for Accommodations [Assistive listening systems, computer-assisted real-time captioning, or sign language interpreter services are available if you ask at least five days before the trial. Contact the clerk’s office for form IMC-410, Request for Accommodations by Persons With Disabilities and Response. (Civ. Code, § 54.8.) ——— Plaintiff's Claim and ORDER to Go to Small Claims Court SC-100, Page “s (Small Claims)yoru Tt]t) Informacién para el demandado (la persona demandada) La “Corte de reclamos menores” es una corte especial donde se deciden casos por $10,000 o menos. Los individuos, o sea las “personas fisicas” y los propietarios por cuenta propia, pueden reclamar hasta $10,000. Las corporaciones, asociaciones, entidades publicas y otras empresas solo pueden reciamar hasta $5,000. (Vea abajo para las excepciones.*) El proceso es rapido y barato. Las reglas son sencillas e informales. Usted es el Demandado—a persona que se esta demandando. La persona que lo esta demandando es el Demandante. Necesito un abogado? Puede hablar con un abogado antes o después del caso. Pero no puede tener a un abogado que lo represente ante la corte (a menos que se trate de una apelacién de un caso de reclamos menores). zCémo me preparo para ir a la corte? No tiene que presentar ningunos papeles antes del juicio, a menos que piense que ésta es la corte equivocada para su caso. Pero lieve al juicio cualquier testigos, recibos y pruebas que apoyan su caso. Y lea “Esté preparado para su juicio” en www.courts.ca.gov/reclamosmenores/preparese. Qué hago si necesito una adaptacién? Si tiene una discapacidad 0 tiene impedimentos de audicién, llene el formulario MC-410, Request for Accomodations. Entregue el formulario al secretario de la corte o al Coordinador de Acceso/ADA de su corte. 2Qué pasa si no hablo bien inglés? Pregintele al secretario de la corte lo mas pronto posible si en el juzgado habré un intérprete disponible y cémo solicitarlo. No siempre estan disponibles los intérpretes de la corte. Otra opcién es llevar a un adulto que pueda interpretar para usted siempre que esa persona no sea un testigo ni un abogado. O puede pedir a la corte una lista de intérpretes particulares disponibles para contratar. ~zDénde puedo obtener los formularios de la corte que necesito? Vaya a cualquier edificio de la corte, la biblioteca legal de su condado, 0 imprima los formularios en www.courts.ca.gov/ smaliciaims/forms (pagina esta en inglés). zQué pasa en el juicio? El juez escuchara a ambas partes. El juez puede tomar su decisién durante la audiencia o enviarsela por correo después. Qué pasa si pierdo el caso? Si pierde, puede apelar. Tendré que pagar una cuota. (El Demandante no puede apelar su propio reciamo.) + Si estuvo presente en el juicio, Ilene el formulario SC-140, Aviso de apelaci6n (Notice of Appeal). Tiene que presentarlo dentro de 30 dias después de que el secretario le entregue o envie la decision (fallo) del juez en el formulario SC-200 o SC-130, Aviso de publicacién del fallo (Notice of Entry of Judgment). Si no estuvo en el juicio, llene y presente el formulario SC-135, Aviso de peticion para anular él fallo y Declaraci6n para pedirle al juez que anule el fallo (decisi6n). Si la corte no le otorga un nuevo juicio, tiene 10 dias para apelar la decision. Presente el formulario SC-140. Para obtener mas informacién sobre las apelaciones, vea www. courts.ca.gov/reclamosmenores/apelaciones. Tengo otras opciones? Si. Si lo estén demandando, puede: . Resolver su caso antes del juicio. Si usted y el Demandante se ponen de acuerdo en cémo resolver el caso, el Demandante tiene que presentar el formulario CIV-110, Solicitud de desestimacién (Request for Dismissal) ante el secretario de la corte. Pidale al Asesor de Reclamos Menores que lo ayude. « Probar que es la corte equivocada. Envie una carta a la corte antes del juicio explicando por qué cree que es la corte equivocada. Pidale a la corte que despida el reciamo.Tiene que entregar (dar) una copia de su carta (por correo o en persona) a todas las partes. (Su carta a la corte tiene que decir que hizo la entrega.) Ir al juicio y tratar de ganar el caso. Lieve testigos, recibos y cualquier prueba que necesite para probar su caso. Si desea que la corte emita una orden de comparecencia para que los testigos vayan al juicio, llene el formulario SC-107, Citatorio de reclamos menores (Small Claims Subpoena) y entrégueselo legaimente al testigo. . Demandar a la persona que lo demand6. Si tiene un reclamo contra el Demandante, y el reclamo se puede presentar en la corte de reclamos menores, tal como se describe en este formulario, puede presentar el formulario SC-120, Reclamo del demandado (Defendant's Claim) y presentarlo en este mismo caso. Si su reclamo excede el limite permitido en la corte de reclamos menores, puede igualmente presentarlo en la corte de reclamos menores si esta dispuesto a limitar su reciamo al maximo permitido, o puede presentar un reclamo por el monto total en la corte apropiada. Si su reclamo excede el limite permitido en la corte de reclamos menores y esta relacionado con el mismo contrato, transaccién, asunto o acontecimiento que el reclamo del Demandante, puede presentar su reciamo en la corte apropiada y presentar una mocién para transferir el reciamo del Demandante a dicha corte, para poder resolver los dos reclamos juntos. Puede ver una descripcién de los montos permitidos en el parrafo anterior titulado “Corte de reclamos menores”. . Aeptar el reclamo del Demandante y pagar el dinero. O, sino puede pagar en ese momento, vaya al juicio y diga que quiere hacer los pagos. No ir al juicio y aceptar el fallo por falta de comparecencia. Si no llega a un acuerdo con el Demandante y no va al juicio (fallo por falta de comparecencia), el juez le puede otorgar al Demandante lo que esta reclamando mas los costos de la corte. En ese caso, el Demandante legalmente puede tomar su dinero, ‘su sueldo o sus bienes para cobrar el fallo. Qué hago si necesito mas tiempo? Puede cambiar la fecha del juicio si: * No puede ir a la corte en la fecha programada (tendré que pagar una cuota para aplazar el juicio), o + Nole entregaron los documentos legalmente (no recibié la orden para ir a la corte) por lo menos 15 dias antes del juicio (6 20 dias si vive fuera del condado), o * Necesita mas tiempo para conseguir intérprete. (Se permite un solo aplazamiento sin tener que pagar cuota para aplazar el juicio). Preguntele al secretario de reclamos menores sobre las reglas y las cuotas para aplazar un juicio. O lene el formulario SC-150 (0 escriba una carta) y envielo antes del plazo a la corte y a todas las otras. personas que figuran en sus papeles de la corte. Adjunte un cheque para pagar los costos de la corte, a menos que le hayan dado una exencién. Necesita ayuda? El Asesor de Reclamos Menores de su ‘condado le puede ayudar sin cargo. _ O visite www.courts.ca.gov/reclamosmenores/asesores. limites en un ‘contra un (Vea el Cédigo de Pro civ, 116.220 (c).) Revised January 1, 2017 Reclamo del Demandante y ORDEN ‘SC-100, Page 5 of 5 Para Ir a la Corte de Reclamos Menores (Reclamos Menores) For your protection and privacy, please press the Clear This Form button after you have printed the form. (ERAT [Seve tie form] =a tor]Sera TtT¢) Information for the defendant (the person being sued) “Small claims court" is a special court where claims for $10,000 or less are decided. Individuals, including "natural persons" and sole proprietors, may claim up to $10,000. Corporations, partnerships, public entities, and other businesses are limited to claims of $5,000. (See below for exceptions.*) The process is quick and cheap. The rules are simple and informal. You are the defendant—the person being sued. The person who is ‘suing you is the plaintiff. Do I need a lawyer? You may talk to a lawyer before or after the case. But you may not have a lawyer represent you in court (unless this is an appeal from a small claims case). How do | get ready for court? You don't have to file any papers before your trial, unless you think this is the wrong court for your case. But bring to your trial any witnesses, receipts, and evidence that supports your case. And read “Be Prepared for Your Trial” at www.courts.ca.gov/smaliclaims/prepare. What if | need an accommodation? If you have a disability or are hearing impaired, fill out form MC-410, Request for Accommodations. Give the form to your court clerk or the ADA/ Access Coordinator. What if | don’t speak English well? Ask the court clerk as soon as possible if your court has a court-provided interpreter available and how to request one. A court-provided interpreter may not be available. Alternatively, you may bring an adult who is not a witness or an attorney to interpret for you or ask the court for a list of interpreters for hire. Where can | get the court forms | need? Go to any courthouse or your county law library, or print forms at www. courts.ca.gov/smaliclaims/forms. What happens at the trial? The judge will listen to both sides. The judge may make a decision at your trial or mail the decision to you later. What if I lose the case? If you lose, you may appeal. You'll have to pay a fee. (Plaintiffs cannot appeal their own claims.) « If you were at the trial, file form SC-140, Notice of Appeal. You must file within 30 days after the clerk hands or mails you the judge's decision (judgment) on form SC-200 or form SC-130, Notice of Entry of Judgment. « If you were nof at the trial, fill out and file form SC-135, Notice of Motion to Vacate Judgment and Declaration, to ask the judge to cancel the judgment (decision). If the judge does not give you a new trial, you have 10 days to appeal the decision. File form SC-140. For more information on appeals, see www.courts.ca.gov/ smaliclaims/appeals. Do | have options? Yes. If you are being sued, you can: + Settle your case before the trial. If you and the plaintiff agree on how to settle the case, the plaintiff must file form CIV-110, Request for Dismissal, with the clerk. Ask the ‘Small Claims Advisor for help. + Prove this is the wrong court. Send a letter to the court before your trial explaining why you think this is the wrong court. Ask the court to dismiss the claim. You must serve (give) a copy of your letter (by mail or in person) to all parties. (Your letter to the court must say you have done so.) + Go to the trial and try to win your case. Bring witnesses, receipts, and any evidence you need to prove your case. To have the court order a witness to go to the trial, fill out form SC-107 (Small Claims Subpoena) and have it served on the witness. Sue the person who is suing you. If you have a claim against the plaintiff, and the claim is appropriate for small claims court as described on this form, you may file Defendant's Claim (form SC-120) and bring the claim in this action. If your claim is for more than allowed in small claims court, you may still file it in ‘small claims court if you give up the amount over the small claims value amount, or you may file a claim for the full value of the claim in the appropriate court. If your claim is for more than allowed in small claims court and relates to the same contract, transaction, matter, or event that is the subject of the plaintiff's claim, you may file your claim in the appropriate court and file a motion to transfer the plaintiff's 's claim to that court to resolve both matters together. You can see a description of the amounts allowed in the paragraph above titled “Small Claims Court.” + Agree with the plaintiff's claim and pay the money. Or, if you can't pay the money now, go to your trial and say you want to make payments. - Let the case "default." If you don't settle and do not go to the trial (default), the judge may give the plaintiff what he or she is asking for plus court costs. If this happens, the plaintiff can legally take your money, wages, and property to pay the judgment. What if | need more time? You can change the trial date if: + You cannot go to court on the scheduled date (you will have to pay a fee to postpone the trial), or You did not get served (receive this order to go to court) at least 15 days before the trial (or 20 days if you live outside the county), or + You need more time to get an interpreter. One postponement is allowed, and you will not have to pay a fee to delay the trial. Ask the Small Claims Clerk about the rules and fees for postponing a trial. Or fill out form SC-150 (or write a letter) and mail it to the court and to all other people listed on your court papers before the deadline. Enclose a check for your court fees, unless a fee waiver was granted. Need help? Your county's Small Claims Advisor can help for free. T “1 _t Or go to www.courts.ca.gov/smaliciaims/advisor. * Exceptions: Different limits apply in an action against a defendant who is a guarantor. (See Code Civ. Proc., § 116.220(c).) Revised January 1, 2017 Plaintiff's Claim and ORDER to Go to Small Claims Court (Small Claims) SC-100, Page 4 of 5 =City AND COUNTY of An FRANCISCO Orice OF THE City ATTORNEY Marleena Green Claims Adjuster DiRECTDIAL: (418) 554-4203 E-MAIL: MARLEENA.GREEN@SFCITYATTY.ORG . March 6, 2020 Jordan Wood 1530F Pershing Dr. San Francisco, CA 94129 RE: Claim of Jordan Wood / Claim Number 20-01563 Department: MTASTRTS Pedestrian, Bicycle & Traffic Engineering Incident Date: January 4, 2020 Claim Filed: January 17, 2020 NOTICE OF ACTION UPON CLAIM . PLEASE TAKE NOTICE THAT An investigation of your claim filed with the City and County of San Francisco has revealed no indication of liability on the part of the City and County. Accordingly, your claim is DENIED. WARNING Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Government Code section 945.6. This time limitation applies only to causes of action arising under California law for which a claim is mandated by the California Government Claims Act, Government Code sections 900 et. seq. Other causes of action, including those arising under federal law, may have shorter time limitations for filing. 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. Please also be advised that, pursuant to Code of Civil Procedure sections 128.7 and 1038, the City and County of San Francisco will seek to recover all costs of defense in the event an action is filed in this matter and it is determined that the action was not brought in good faith and with reasonable cause. Very truly yours, DENNIS J. HERRERA City Attorney Helin Gley Marleena Green Claims Adjuster Fox PLAZA - 1390 MARKET STREET, 7TH FLOOR- SAN FRANCISCO, CAUFORNIA 94102-5408 RECEPTION: (415) 554-3900. FACSIMILE: (415) 554-8795 1n:\claim\cl2020\20-01563\01433818.docxClaim of: Jordan Wood Claim Filed: January 17, 2020 I, Marleena Green, say: I am a citizen of the United States, over eighteen years of age, and not a party to the within action; that I am employed by the City Attorney's Office of San Francisco, Fox Plaza, 1390 Market Street, 7th Floor, San Francisco, CA 94102. That on March 6, 2020 I served: NOTICE OF ACTION UPON CLAIM by placing a true copy thereof in an envelope addressed to: Jordan Wood 1530F Pershing Dr. San Francisco, CA 94129 Following ordinary business practices, I sealed true and correct copies of the above documents in addressed envelope(s) and placed them at my workplace for collection and mailing with the United States Postal Service. I am readily familiar with the practices of the San Francisco City Attorney's Office for collecting and processing mail. In the ordinary course of business, the sealed envelope(s) that I placed for collection would be deposited, postage prepaid, with the United States Postal Service that same day. I declare under penalty of perjury that the foregoing is true and correct. Executed on March 6, 2020 at San Francisco, California. Hatt... Gut, Marleena Green DECLARATION OF SERVICE BY MAIL n:\claim\cl2020\20-01563\01433816.docx.CLAIM AGAINST THE CITY AND COUNTY OF SAN FRANCISCO Before completing this form please read the instructions on the back. Untimely claims will be returned. Please submit this form and supporting documentation to the Controller’s Office, Claims Division, 1390 Market Street, 7" Floor, San Francisco, CA 94102 in person or by mail. *=REQUIRED ** = REQUIRED IF KNOWN 1. Claimant’s Name and Home Address (Please Print Clearly) * Jordan Wood 2. Send Official Notices and Correspondence to: * 1530F Pershing Dr 1530F Pershing Dr City San Francisco Stateca_ Zip 94129 city San Francisco State Zip 94129 Telephone Evening (418) 802-3288 _| | Telephone °™*™* — (415) 802-3288 3. Date of Birth 4. Social Security Number 5. Date of Incident [6. Time of Incident (as or pm 08/06/1978 100-86-6782 * 01/04/2020 [** 2:20 AM 7. Location of Incident or Accident “* Laurel St. intersection of Washtington St. 8. Claimant Vehicle License Plate #, Type, Mileage, and Year ™ 4853030 9. Basis of Claim. State in detail all facts and circumstances of the incident. Identify all persons, entities, property and City departments involved. State why you believe the City is responsible for the alleged injury, property damage or loss. * Applied the brakes to come to stop at a downhill stop sign on the letter "S" going 3 mph. Front tire slipped on letter the motocycle flipped over. Paint on the letter "S" was very thick and had no grip Was light moisture on the letter from dew. | called 911 and decided to go to police station after | returned home and picked up my car to drive myself there. bee of City Employee who allegedly caused injury or loss Name, |.D. Number and City Department Type of City Vehicle Vehicle License Number and Bus or Train Number bee 10. Description of Claimant's injury, property damage or loss * Injuries documentation. Swollen wrist, shoulder, and stiff neck for a week. Still having wrist nerve pain on 01/17/20 ___ ITEMS + Engine Cover, 11, Amount of Claimant's property damage or loss and method of computation. Attach supporting (See Instructions) lever, $ 134.00 Fairing replacement $ 498.00 Barend, sliders, mirror,peg $ 256.00 Motorcycle damage - paint, frame sliders, bar ends, shifter, foot peg, engine cover. Personal safety equipment (i.e helmet, boots) Boots, Helmet $ 429.00 TOTAL AMOUNT $1,317.00 __ Court Jurisdiction: Limited (up to $25,000) Unlimited (over $25,000) [] CRIMINAL PENALTY FOR PRESENTING A FALSE OR FRAUDULENT CLAIM IS IMPRISONMENT OR FINE OR BOTH. (PENAL CODE §72) 12. Witnesses (if any) Name Address Telephone 4. 2. 13. Do Not Write In This Space * Signature of Claimant or Representative Date Print Name Relationship to Claimant