10000000959

Case 6:12-bk-28006-MJ Doc 209 Filed 10/24/12 Entered 10/25/12 11:01:31 Desc
Main Document Page 1 of 16

Bl6A (Official Fonn 16A) (12/07)
Form 16A. CAPTION (FULL)
United States Bankruptcy Court
r
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!
I
______ District Of ______ _

[Set rth here all names including married,
maiden, and trade names used by debtor within
last 8 years.]
Debtor
) Case No. lo \ 2.-bk- 2'0 -XV\J"
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Chapter----'------
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O'OJec.;\-\\:10. -\-o ?e\-,.lnon
Last four digits of Social-Security or Individual Tax - Payer- )
Identification (ITIN) No(s)., (if any): -------- )
Employer Tax-Identification (BIN) No(s)., (if any): __ _
)
)
)
[Designation of Character of Paper]
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NOTE TO USERS OF THIS FORM:
1) Attach this form to the last page of a proposed Order or Judgment. Do not file as a separate document.
2) The title of the judgment or order and all service information must be filled in by the party lodging the order.
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I. SERVED BY THE COURT VIA NOTICE OF ELECTRONIC FILING ("NEF"l - Pursuant to controlling General Order(s)
and Local Bankruptcy Rule(s), the foregoing document was served on the following person(s) by the court via NEF and
hyperlink to the judgment or order. As of , the following person(s) are currently on the Electronic
Mail Notice List for this bankruptcy case or adversary proceeding to receive NEF transmission at the email address(es)
indicated below.
0 Service information continued on attached page
11. SERVED BY THE COURT VIA U.S. MAIL: A copy of this notice and a true copy of this judgment or order was sent by
United States Mail, first class, postage prepaid, to the following person(s) and/or entity(ies) at the address(es) indicated
below:
Ill. TO BE SERVED BY THE LODGING PARTY: Within 72 hours after receipt of a copy of this judgment or order which
bears an "Entered" stamp, the party lodging the judgment or order will serve a complete copy bearing an "Entered" stamp
by U.S. Mail, overnight mail, facsimile transmission or email and file a proof of service of the entered order on the
following person(s) and/or entity(ies) at the address(es), facsimile transmission number(s), and/or email address(es)
indicated below:
This form is mandatory. It has been approved for use by the United States Bankruptcy Court for the Central District of California.
August 2010 F 9021-1.1.NOTICE.ENTERED.ORDER
J a1nes l ~ Cr;nvford
111') \!""" J)m-, San lkrnanlino, t'.\ 'iLIOl l'lh>IH': ')')'1-!ll,l;.;ol.',
l->\Lul: j:nw,hn:iii'IOI de11Inac.< on I
Date: October 24, 12
United States Bankruptcy Court
Central District of California- Riverside Division
3420 Twelfth Street
Riverside, California 92301-3819
RE: Case No.6: 12-bk-28006-MJ
Dear Sir or Madam:

I am writing this letter on behalf of myself, James Crawford, in response to a letter that was mailed to me regarding the
City of San Bernardino California's bankruptcy and the current debt that they have with me. I was involved in a car
accident, which involved an employee of the City of San Bernardino. After the investigation was complete, the police
officer was found to have performed an unsafe U-turn and was therefore the responsible party. As the City of San
Bernardino is self-insured, I filed a claim with them and it was approved on May 14, 2012, in the amount of $761.94,
(Claim# 0212-12-00087) which was the amount of the original estimate from Caliber Collision in San Bernardino, CA.
While being repaired, additional damage was found in the amount of $406.92. Kenneth Potashnik, a Service Advisor for
Caliber Collision, contacted Rhonda Haynes (a supervisor with City of San Bernardino Risk Management) and was told
by her to fax over the additional damages. Once reviewed, she would give the ok to proceed. Caliber Collision received
the ok from Rhonda Haynes and proceeded with the supplemental damage repair. Caliber Collision was informed by the
City of San Bernardino Risk Management that an automatic stay had been placed on the supplemental claim of $406.92
upon trying to collect. I have received multiple calls from Caliber Collision in regards to this payment.
I have also received calls from Enterprise Rental Car Co. regarding the $407.02 that the City of San Bernardino approved
for the rental that was provided during the time my vehicle was being repaired. Enterprise Rental Car Co was informed by
the City of San Bernardino Risk Management that an automatic stay had been placed on the amount billed of $407.02
upon trying to collect.
I have included copies of the police report from the accident, the approved claim against the City of San Bernardino, the
invoice from Enterprise Rental Car Co and the supplemental estimate from Caliber Collision. If the debt is not paid, the
bills will be sent to collections against myself and will adversely affect my credit and good standing. The total amount of
the above items is $813.94. This presents a hardship for my family. With the City of San Bernardino being self-insured, I
am requesting that they make good on this claim.
Thank you for your time.
Sincerely,
1
~ c > JJ t:,Jc,
James B Crawford I
Claimant
STATE OF CAliFORNIA
TRAfFIC COLLISION REPORT
CHP 555 CARS Page 1 (Rev 1-03) OPI 061
Sf'ECW. C:ONOITIONS
1 1 -82 INVESTIGATION
Or:iOUTY EMERGENCY VEHICLE

MTNVIEW AVE
!WAE(FIRST. IIIOCl.E. LASll
JAMES BENEL CRAWFORD
1479 MORSE DR
Q
JUDICIAl. OISllOICT
SBSUP
DI!LTRIC.T
BERNARDINO 3610
11116/20 ll
DAY OF WEEK
WEDNF.SDAY
:IN'Em' EOUIP.
G 1997
CA 92404
IEA"T
02
Pall" of
4
LOCAL FOPORT NUMBER
2011-32440
NClCI I.D.
3610
PltOTOQR.\PMS BY:
DIIONE
R. YANDELL
STATE.
CA

BIRTKOATE
Doy
PO\JCYN\Jio4BER

---------------
CA ... T TCI'II'IIC
VfK VEIJI lAAKE /MODEll
DATERE\IIEWED
STATE OF CALIFORN!.A.
TRAFFIC COLLISION CODING
CHP 55$ CARS Page2 (Rev. 1-03) OPI 061
DATe 01' (UO. MY "<AA)

I Jll.6f20 II 1154 3610
OWI<11
PROPERTY
DAMAGE oaeRIPTIOO 01' DAIUOE
SEATING POSITION
'
OCCUPANTS
A.
A- NONE IN VEHICLE
B-UNKNOWN
C LAP SEL T USED
I 2 3 I-DRIVER
D LAP BELT NOT USED
2TO a- PASSENGERS
E SHOULDER HARNESS USED
4 5 6
7 STA. WGN REAA
F SHOULDER HAANESS NOT USED
G -LAPISHOULOER HARNESS USED
8- RR. OCC iRK. OR VAN
9.- POSITION UNKHOWN
H LAPISHOULDEA HARNESS NOT USED
7
J PASSIVe RESTRAINT USED
0-0THER
K PASSIVE RESTRAINT NOT USED

i OWNER ...OORf.SS
SAFETY EQUIPMENT
l AIR BAG DEPLOYED
MIC BICYCLE HELMET
M -AIR BAG NOT DEPLOYED ORMR PASSENGER
H-OTHER V-NO X-NO
P NOT REQUIRED
W-V$ Y-YES
CHILD RESTRAINT
EJECTED FROM VEHICLE
0 -IN VEHICLE USED
0 NOT EJECTED
R - IN VEHICLE NOT USED
I FULLY EJECTED
S -IN VEHICLE USE UNKNOWN
2 PARTIALLY EJECTED
T IN VEHICLE IMPROPER USE
JUNKNOWH
U NONE IN VEHICLE
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK rl SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMAR'(COLUSION FACTOR
TRAFFIC CONTROL DEVICES I 2 3
SPECIAL INFORUATlON 1 2
UST NUMIItR c-l Of' PART"f AT FAULT
2
VC SECTION VIOLATED: A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL
A nw3 o
B CONTROLS NOT FUIICllONING 8 CEll PHONE HANDHELD IN USE
X
8
OTHER IMPROPER DRMNG" C CONTROLS OBSCURED c Cell PHONE HANOSFREE IN USE
X
D NO CONTROLS PRESEHr I FACTOR
X X
D CELL PHONE NOT IN USE
c OnlER THAN DRIVER" TYPE OF COLLISION E SCHOOL BUS RELATED
D UNKNOWN A HEADON F 75 fT MOTORTRUCK COMBO
X
B SIDESWIPE G 32 FT TIWLER COMBO
C REAREND H
WEATHER (IMRK I TO 2 ITEMS)
X
D BROADSIDE I
X A CLEAR E HITOBJECT J
B CLOUDY f OVERT'URNED K
C RAINING G VEHICLE I PEDES'TRIAN L
D SNOWING H OTHER: M
E FOG I VISIBILITY FT. N
F OTHER: MOTOR VEHICLE INVOLVED WITtl 0
G WIND A NON COLLISION
p
"'
UGHTING)) B PEDESTRIAN Q
X
A DAYliGHT
X
C OTHER MOTOR VEHICLE
l 2 3
OTHER ASSOCIATED FACTORS
B DUP:DAWN D MOTOR VEHICLE ON OTHER ROADWAY
(IMRK 1 TO 21TEMS)
C DARK-STREETLIGHTS E PAAI<EOMOTOR VEHICLE
f..::;'t:
A
KJECtKIH'W)LATtD
errto a=
D DARK NO STREET LIGHTS F TRAIN , .. , ...
E DARK STREET LIGHTS NOT G BICYCLE

..
B
\ICJEC.riOIIYia..fltED CITLD
a :a
FUNCTIONING
H ANIMAL:
..
Pall"2 o! 4
..........sEll
2011-32440
oonFIED
(]YEs ONo
INATTENTION CODES
A CELL PHOIE IIAHDHB.D
B CELL PHONE HANDSFREE
C ELECTRONIC EQUIPMENT
D RADIO I CO
E.SIJIOKING
F-EATING
G-CHILDREN
H-ANIMALS
I PERSONNEL HYGIENE
J-REAOINC
K-OTHER
3

COLUSION
A STOPPED
B PROCEEDING STRAIGHT
C RAN OFF ROAD
D MAKING RIGKTTURN
E MAKING LEFT TURN
F MAKING U TURN
G IIACKJoiG
If SLOWING I STOPPING
I PASSING O'TliERVEHICLE
J CHANGING LANES
K PARKING MANEUVER
L EWTCRING TRAFFIC
M OTHER UNSAFE TURNING
N XING uno OPPOSING LANE
0 PARKED
P MERGING
Q TRAVELING WRONG WAY
ROTHER":
SOBRIETY DRUG
ROADWAY SURFACE
"""" "'
:-:'-:t .... : c
VCif.CflOMYI(K..I.'RD. C!Tll
g:s I 2 3
PHYSICAL
....
(MARK 1 TO 2 ITEMS}
X
A DRY 1 F!XED OBJECT: .::'}
B WET 0 \ r-: .. tt;' :t ..
.. ,
X X A HAD NOT BEEN DRINKING
C SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT: B UNDER INFLUENCE
0 SLIPPERY (MUDDY, 01\. Y, ETC.) F INATTENTION';
C HBD NOT UNDER INFLUENCE"
ROADWAY CONDIT10N(SI
0 STOP & GO TRAFFIC 0 HBO IMI'AIRMEKT UNKNOWN"
(MARK' TO 2 ITEMS)
PEDESTRIAN'S ACnONS H ENTERING I li;AVING RAMP E UNDER DRUG INFlUENCE"
A HOLES, DEEP RliT'
X
A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION
I
F IMPAIRMENT PHYSICAL
8 LOOSE MATERIAL 01'1 ROADWAY
8 CROSSING IN CROSSWALK
J UNF AM! LIAR ....,T\1 ROAO C IMPAIRMENT NOT KNOWN
X
C OBSTRUCTION ON ROAOWAY' AT INTERSECTION K DEFECTIVE 1/EH. EQUIP.; CITED H NOT APPUCABI.E
0 CONSlRUCTION -REPAIR ZONE C CROSSING IN CROSSWALK NOT
s:s
I I
I SlEEPY 1 FATIGUED
E REDUCED ROADWAY WIDTH
AT INTERSECTION
F FLOODED 0 CROSSING NOT 1H CROSSWALK L UNINVOLVED VEHICLE
G OTHER". E IN ROAO -INCLUDES SHOUlDER hi OTHER":
H NO UNUSUAL CONDITIONS f NOTIN ROAD X )( N NONE APPARENT
Q APPROACHING I LEAVING SCHOOL BUS 0 RUNAWAY VEHICLE
SKETCH
FOR SKETCH DIAGRAM, SEE PAGE 4
0
MISCELLANEOUS

. \;
INDICATE NORTH

'
'Lc,. v
STATE OF CALIFORNIA
INJURED I WITNESSES I PASSENGERS
Pa J 01 4
CHP 555 CARS Pag_e 3_{Rev OP! 061
ge
DATE OF COLLISION (MO. DAY YEAR) TIME(2(00) NCICII OFFICER I. D.
NUMBER
ll/J6/2011 1154 3610 50252 2011-32440
IMTNUS PMSENGEJI EXTENT OF INJURY('X' ONE) INJURED WAS ('X' ONE)
"ARTY SEAT AlA ... sex l!N'ETY
OM..Y ONLY
NUMBER POS.
E.Eelel
FATAL nVEI'E OTHER \IISIOU:. COIAP\.AINT
tiA(l EQuiP.
DRIVER PI-SS. PE1l. BICYCLI:rT OT><ER
INJURY Ill .fURY OF PAIN
0'
IKl
M
0 0 0 0 0 0 0 0 0
2 3 M G 0
NAME I D.O.B. I ADDRESS TELE1'HONE
OFFICER TONY W111TE 710 N. D ST SAN BERNARDINO CA 92401 (909)384-5742
(INJURED ONLY) TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
n
VICTIM OF VIOLENT CRlME NOTIFIED
o' 0 0 0 0 0 0 0 0 0 0
NAME I O.O.B.I ADDRESS
TELEPHONE
(INJURED OHL Y) TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
D
VICTIM OF VIOLENT CRIME NOTlFIED
o' 0 0 0 0 0 0 0 0 0 0
NMIE I 0.0.8.1 ADDRESS TELEPHONE
(INJURED ONLY) TRANSPORTl:D BY: TAKEN TO:
DESCRIBE INJURIES:
n lllCTIM OF VIOLENT CRIME NOTIFIED
o'
I
0 0 0 0 0 olo ol 0 ol _l
NAME I O.O.B.I ADDRESS TELEPHONE
DESCRIBE INJURIES:
n OF VIOLENT CRIME NOTIFIED
o"
I
0
I
0 0 0 0 I o_loloJ 0
lol
I
H.o.ME I 0.0.9. I ADDRESS TELEPHONE
.
DESCRIBE INJURIES:
....
n \ENT CRIME NOTIFIED
o'
l
0 lo
D 0 0
I ololol
0 I Cli-o I
I I
NJWS:InnR
'
... .:
... r..; v
{INJURED ONLY) TIW-ISPORlED BY: TAKEN TO:

DESCRIBE INJURIES:
n VICTIM OF VIOLENT CRIME NOTIFIED
PREPARER'SNAMV
I.D.NUMBER
IMO. CAY YEAA
MO. DAY YEIIR
J.D. SHUCK S02S2 1111612011
.J)-1;?- /I
/
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE I
DATE OF INCIDENT
11116/ll
TIME
1154
NCIC
3610
OFFICER 1.0.
50252
REPORT NUMBER
2011-32440
FACTS:
NOT! FICA TION:
On Wednesday 11/16/11 I was assigned to the San Bernardino Police Department Traffic Division.
I was in full uniform and riding a marked black and white police motorcycle. At about 1213 hours,
I was dispatched to the area of MtnView Ave and 61h St regarding this non-injury traffic collision
involving an on-duty emergency vehicle. Responding from San Bernardino Community Hospital, I
arrived on scene at about 1221 hours. All times, speeds, and measurements are approximate.
Measurements were obtained by pacing. Statements, vehicle damage, and evidence established the
facts to this collision.
SCENE:
This collision occurred on Mtn. View Ave approximately 60' S/ of 7th St, which is a residential
district. Mtn. View Ave is a 4-lane north/south asphalt paved roadway. There are two lanes in each
direction with the north/southbound lanes being separated by a single set of double yellow solid
lines. In this area south of th St is a construction zone marked with orange cones that closed down
the #2 lane for northbound traffic. All roadway markings and signs were in good working condition.
PARTIES:
D-1 (Crawford) was found standing on the east sidewalk of MtnView Ave S/ of 7
111
Stand was
identified by his California Drivers License. He said he wasn't injured in this collision.
V-1 (Ford) was found on its wheels parked along the w/c/1 ofMtn. View AveS/ of7
1
h St: The
vehicle sustained minor damage to the front end that consisted of both outer sides of the front metal
bumper being flared out and downward slightly. ln addition, there was a small black scuffmark on
the upper portion of the left side of the grill. Also, there was a small dent to the front license plate.
V -2 (Toyt) was found on its wheels parked on Mtn. View Ave, #2 lane, within a coned construction
zone and was facing northbound. The vehicle sustained moderate damage to the left rear quarter
panel that consisted of a large area of black scuffmarks. The vehicle is owned by the San
Bernardino Police Department and used by police officers in the performance of their duties. The
vehicle isn't equipped with at least one forward facing red light and a siren, but does have a radio
system for the purposes of communication. However, pursuant to CVC Section 165 (b) (1 ), this
vehicle qualifies as an authorized emergency vehicle.
D-2 (Beall) was found standing on the east sidewalk of Mtn. View Ave S/ of 7
1
h Stand was
identified by his California Drivers License. He said he wasn't injured in this collision. At the time
of thts colhs10n, the San Bemardmo Police Department employed a police officer. He was
working in plain clothes and conducting surveillance activit .
J.D. NUMBER DATE ,:-._'\ RI:VIEWER'S NAME DATE
'
50252 t:'!e:-;!?l49,..J7C-5
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL
OF INCIDENT
ll/16/11
TIME
1154
PHYSICAL EVIDENCE:
NCICNUMBER
3610
OFFICER 1.0.
50252
PAGE2
REI'ORT NUMUER
2011-32440
The physical evidence in this collision consisted of vehicle damage skids marks found at the
scene.
PHOTOGRAPHS:
Forensic Specialist R. Yandell responded to the scene for photographs.
STATEMENTS:
D-1 (Crawford) said he was traveling southbound on Mtn. View Ave, #I lane, approaching 7
1
h Stat
about 30-35 mph. However, he had slowed down to about 25 mph for the upcoming construction
zone and then down to about 20 mph. At that time, he noticed D-2 (Beall) facing in a northeast
direction with the back end of his vehicle protruding out about 3' into the southbound #1 lane.
Crawford said Beall moved forward and cleared the southbound lane at which time he let off of his
brake pedal. Upon doing so, Crawford said Beall had backed up into the #I lane for southbound
traffic directly in front of him. Crawford said he attempted to avoid Beall by applying his brakes
aggressively. However, he was unsuccessful as the front of his car collided with the left rear quarter
panel ofV-2. Crawford didn't provide any further statement and the interview with him was
concluded.
D-2 (Beall) said prior to this collision he was parked along the southside of7
1
h St W/ of Mtn. View
Ave doing surveillance in the area. At that time, he proceeded to go eastbound and stopped at the
stop sign of the intersection. He identified himself as a police officer and asked the construction
workers on the East Side of the street if he could park within their cone pattern to do his
surveillance. The workers told him he could do so and Beall proceeded to look northbound for
oncoming traffic. Beall said he noticed Crawford trave1ing southbound on Mtn. View Ave, #1 lane,
approximately two telephone poles away. He estimated his speed to be about 25-30 inph. Beall said
he proceeded to make a right tum and then immediately made aU-tum in an attempt to park in cone
pattern on the East Side of the street. Upon doing so, the left rear comer ofhis vehicle was struck by
the front end ofV-1. Beall said though he initially estimated Crawford's speed to be 25-30 mph
after impact he believed his speed to be closer to 50 mph. He didn't provide any further statement
and the interview with him was concluded.
PREPARER'S NAMF.
J.Shuck
>
I.D. NUMBER
50252
tl/16/l ....
REVIEWER'S NAME DATE
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL
DATE OF INCIDENT
11116/11
TIME
1154
OPINION AND CONCLUSIONS:
NCICNUMBER OFFICeR I.D.
3610 50252
PAGE3
REPORT NUMBER
2011-32440
Beall was working as an on-duty police officer, in plain clothes, employed by the San Bernardino
Police Department. He was operating an authorized emergency vehicle. D-l (Crawford) was
traveling southbound on Mtn. View Ave, #I lane, approaching 7
1
h Stat about 35 mph. Beall
proceeded to make a right turn from eastbound ih St onto Mtn. View Ave and after a short distance
proceeded to make a U-tum in an attempt to park inside a construction zone cone pattern on the East
Side of the roadway. He had made his U-tum directly in front of Crawford who attempted to avoid
Beall by braking aggressively. As he did so, Crawford's vehicle began to veer to the left side ofhis
lane. However, he was unable to avoid a collision causing the front end ofV-1 (Ford) to collide
with the left rear comer of V -2 (Toyt).
AREA OF IMPACT:
The area of impact was found to be 60'S/ of the s/c/1/p ofih Stand 23' El of the w/c/1 ofMtn. View
Ave.
CAUSE:
0-2 (Beall) caused this collision by making an unsafe U-tum in a residential district in violation of
CVC Section 22103.
RECOMMENDATIONS:
None.
!.D. NUMBER DATE REVIEWER'S NAME DATE
50252 11116/11
May 14,2012
James Crawford
14 79 Morse Drive
San Bernardino, CA 92404
Re: Claimants:
Date of Loss:
Claim No.:
Dear Mr. Crawford:
HUMAN RESOURCES DEPARTMENT
LINN LIVINGSTON - DIRECTOR
300 North '"D" Street San Bernardino CA 92418-0001
909.384.5161 Fax: 909.384.5397
www.sbcity.org
James Crawford
11/16/11
0212-12-00087
We have completed our investigation. Your claim in the amount of$761.94 has been
approved for payment based on the estimate from Caliber-San Bernardino.
Before a check can be issued, we will need a signed release. We have enclosed a release
to be executed in front of a witness. Have the witness sign and print their name in the
place provided under your signature.
Return the original, signed release. Keep a copy for your records. Issuance of a check
takes approximately 21 days from the time that we receive your executed release in our
office.
If you have any questions regarding this matter, please contact this office at (909) 384-
5308.

Steven Dokken
Safety Officer
Risk Management Division
PERSONNEL RISK MANAGEMENT WORKERS' COMPENSATION
IN 04!SlPM
OUT 10:43AM
CALE
UNIT 1
UNIT # 7FQSB
LIC# 6UKHS
MODEL ALTI
COLOR SILVE
IN 11365
OUT 11281
UNIT 2
UNIT # 7FCNR
LIC# 6RLS4
MODEL PATR
COLOR BLACK
IN 36490
OUT 363 98
UNIT 3
UNIT # 7G883
LIC# 6USW8
MODEL SANF
COLOR GRAY
IN 12720
OUT 12090
CLAIM INFO
POL/CLAIM/PO
0212-12-0008
INSURED
LOSS DATE
7/02/12
6/20/12
DAR DAY
5
4
4
K
THEFT ACCI ENT C
TYPE CAR
FORD
SHOP CALIBER COLL
PHONE 909-88 -2121
NAME UNKNOWN *
L/L d
ENTERPRISE RENT-A-CAR COMPANY OF LOS ANGELES, LLC
RENTAL AGREEMENT
D322506
PAGE 1 OF 1
909-888-3241
CA 92401-2008 3262
229 SOUTH E STREET
SAN BERNARDINO
RENTAL TYPE I
SOURCE C63653 - 999
RENTER
JAMES CRAWFORD
1479 MORSE DR.
SAN BERNARDINO CA 92404-
LOCAL:
(H) 951-830-2954 (W) 951-830-3888
DR. LICENSE XXXX5003
STATE CA EXPIRE 3/30/14
DOB 3/30/72 HT WT
EYES HAIR
B.S.#
EMPLOYER
INTMODAL
BILL TO Y CUST # SB23201
SAN BERNARDINO CITY RISK MGMT
ATTN: DOKKEN*STEVEN*
300 NORTH D STREET
SAN BERNARDINO
909-384-5308
ADDITIONAL DRIVER
NONE
92418
PERMISSION TO LEAVE STATE
YES X NO
CA
STATES CA ONLY, NO SMOKING, NO
CUSTOMER SIGNATURE ON FILE
INFORMATION
AMOUNT PD.BY TYPE
35.64 AMX SALE
DATE AUTH
7/02/12 589365
CLOSED TICKET PAYMENT INFO
CLOSED TICKET PAYMENT INfO
<< Ll88606
SUMMARY OF CHARGES
DAY = CALENDAR DAY
MILES
NO CHARGE
2 DAYS
11 DAYS
SALES TAX
TOTAL CHARGES
DEPOSITS
REFUND
(iii
@
28.99
31.99
8.00
BILL TO CUST SB23201
57.98
351.89
32.79
442.66
35.64
407.02
OPENED BY #109JO LESLIE A LEWIS
CLOSED BY #755K7 JESSICA L MEYER
3VH3 1.o=o2
CALIBER - SAN BERNARDINO
RESTORING THE RHYTHM OF YOUR LIFE
1197 E 3RD ST, SAN BERNARDINO, CA 92410
Phone: (909) 889-2121
FAX: (909) 384-0186
Preliminary Supplement 2 with Summary
Workfile ID:
Federal 10:
State EPA:
BAR:
Customer: CRAWFORD, JAMES
Insured: CRAWFORD, JAMES
Type of loss:
Point of Impact: 11 Left Front
Owner:
CRAWFORD, JAMES
1479 MORSE DR
SAN BERNARDINO, CA 92404
(951) 830-2954 Cellular
(909) 889-1902 Day
Year: 1997
Make: FORD
Model: RANGER 4X2 SUPERCAB
Color: RED Int:
5 Speed Transmission
Anti-Lock Brakes (2)
Clear Coat Paint
6/27/2012 9:37:19 AM
Written By: Kenneth Potashnik
Policy#:
Date of Loss:
Inspection Location:
CAUSER - SAN BERNARDINO
1197 E 3RD ST
SAN BERNARDINO, CA 92410
Repair Facility
(909) 889-2121 Business
VEHICLE
Claim#:
Days to Repair: 0
Insurance Company:
CUSTOMER PAY
Body Style: 2D P/U VIN: 1FTCR14X2VPA05084 Mileage In:
Engine:
Production Date:
Condition:
Cloth Seats
Driver Air Bag
Dual Mirrors
6-4.0L-FI License:
State:
Job#:
Intermittent Wipers
Overdrive
Power Brakes
029995
Mileage Out:
Vehicle Out:
Power Steering
Rear Step Bumper
Styled Steel Wheels
I'
33-'
Page 1
~
0
.
.:: CRAWFORD, JAMES
Vehicle: 1997 FORD RANGER 4X2 SUPERCAB 2D P/U 6-4.0L-FI RED
Line Operation Description Qtv Extended Labor Paint
Price$
1 FRONT BUMPER
2 R&l R&l bumper assy 0.5
3
*
Rpr BumQer chrome (POLISH ONLY) Q,5_
4 Rep I Impact strip graphite 1 52.85 0.4
5 SOl FRONT LAMPS
6
*
S02 Rep I LT Headlamp assy 1 11.5..Z.Q 0.5
7 SOl Aim headlamps 0.6
8
*
S02 Rep I LT Park/marker lamp 1
~
0.3
9 S02 R&l RT Headlamp assy 0.5
10 S02 R&l RT Park/marker lamp 0.3
11 S02 HOOD
12
*
S02 Rpr Hood 1.0 2.8
13 S02 Add for Clear Coat 1.1
14 GRILLE
15
**
S02 Rep I A/M Grille w/chrome molding graphite 1
28.Jill 0.5 1.5
16 S02 Overlap Major Adj. Panel -0.4
18
*
S02 Rpr Header panel Q,5_ 1.0
21 # HAZARDOUS WASTE REMOVAL 1 3.00 X
22 # P TINT COLOR FOR MATCH 1 0.5
23 # A TINT MATERIALS 1 10.00 T
24 # S02 A DE-NIB AND POLISH 1 10.00 T
25 # S02 Rpr D DE-NIB AND POLISH LABOR 0.5
SUBTOTALS 349.49 6.6 5.9
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 326.49
Body Labor 6.6 hrs @ $ 46.00 /hr 303.60
Paint Labor 5.9 hrs @ $46.00 /hr 271.40
Paint Supplies 5.9 hrs @ $ 34.00 /hr 200.60
Miscellaneous 23.00
Subtotal 1,125.09
Sales Tax $ 547.09 @ 8.0000% 43.77
Grand Total 1,168.86
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,168.86
6/27/2012 9:37:19 AM 029995 Page 2
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0
;-: CRAWFORD, JAMES
.
Vehicle: 1997 FORD RANGER 4X2 SUPERCAB 2D P/U 6-4.0L-Fl RED
SUPPLEMENT SUMMARY
Line Operation Description Qty Extended Labor Paint
Price$
Changed Items
5 S01 Rep I LT Headlamp assy 1 -112.97 -0.5
6
*
S02 Rep I LT Headlamp assy 1 115.76 0.5
7
*
S01 Rep I LT Park/marker lamp 1 .:2UJ
-0.3
8
*
S02 Rep I LT Park/marker lamp 1 59.88 0.3
Deleted Items
9 HOOD
10
*
Rpr Hood (POLISH ONLY) -0.5
12 Rep I Grille w/chrome molding graphite 1 -120.18 -0.5 -1.5
13 Add for Clear Coat -0.6
Added Items
9 S02 R&I RT Headlamp assy 0.5
10 S02 R&I RT Park/marker lamp 0.3
11 S02 HOOD
12
*
S02 Rpr Hood 1.0 2.8
15
**
S02 Rep I A/M Grille w/chrome molding graphite 1 2.a..QQ 0.5 1.5
18
*
S02 Rpr Header panel 0.5 1.0
24 # S02 A DE-NIB AND POLISH 1 10.00 T
25 # S02 Rpr D DE-NIB AND POLISH LABOR 0.5
SUBTOTALS -12.24 2.3 3.8
6/27/2012 9:37:19 AM 029995 Page 3
__ P_r_e_li_m_in_a_rv_s_u_P_P_Ie_m_e_n_t_2_w_it_h_s_u_m_m_a_rv __________ 0.
Vehicle: 1997 FORD RANGER 4X2 SUPERCAB 2D P/U 6-4.0L-FI RED 'C:-J
TOTALS SUMMARY
Category Basis Rate Cost$
Parts
Body Labor
Paint Labor
Additional Supplement Labor
Paint Supplies
Additional Supplement Materials/Supplies
Miscellaneous
2.3 hrs @
5.9 hrs @
5.9 hrs @
$ 46.00 /hr
$ 46.00 /hr
$ 34.00 /hr
-22.24
105.80
271.40
-96.60
200.60
-71.40
10.00
Subtotal 397.56
Sales Tax $116.96 @ 8.0000% 9.36
Total Supplement Amount 406.92
NET COST OF SUPPLEMENT 406.92
CUMULATIVE EFFECTS OF SUPPLEMENT{S)
Estimate 761.94 Kenneth Potashnik
Supplement SOl 0.00 Kenneth Potashnik
Supplement S02 406.92 Kenneth Potashnik
Job Total: $ 1,168.86
INSURANCE PAY: $ 1,168.86
CALIFORNIA LAW PROVIDES THAT YOU HAVE THE RIGHT TO SELECT THE REPAIR FACILilY OF YOUR CHOICE.
If there is no labeling of part type in the Description column, it is assumed to be New-OEM.
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 GUILlY 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 lYPES: 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 QUANTilY, INCL=INCLUDED,
MISC=MISCELLANEOUS, NAGS=NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ=NON ADJACENT,
0/H=OVERHAUL, OP=OPERATION, NO=LINE NUMBER, QlY=QUANTilY, 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. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY
SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT.
6/27/2012 9:37:19 AM 029995 Page 4

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Case 6:12-bk-28006-MJ Doc 209 Filed 10/24/12 Entered 10/25/12 11:01:31 Desc

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