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Home My WebLink About26- Public Comment UbL - tJ-�� if •I.: tl•t,;rt : IW11 JLH1-e L!mWI5 IU : �V!L4JJS_llbt..r PAGE 1,•2 JERRY LEWIS .pm cofp i.CAWORNY - RAt OWN NOUO CHIC.SUµC,N6 CC.uWTnU. L sv C`OAA01I T((S, V i �li� � 1,S6anCOKSWAAKNU[ sorts 2 `°"""A" iaousE Off' T�5F3ttflIIU IIE�W.CL.CA9D77.A1,. fOR'IfIGN OPt'MT,ONt - 1Of-:Y✓5�0 UGISL^n"~c" rfAu"sI"'31EU TCC/•tmall, Ueshinglufl, iK 20515-0510 ON 1NTiLL,GINCF IIMRlL LTATLI 1 www.hool�A�ITTY e+..�:1 December 9, 1999 To Whom it May Concern: In 1997 , Congressman George E. Brown, Jr. and I decided to work together to solve a serious housing blight problem suffered by the City of San Bernardino, California. Much of the condition was created by an enormous inventory (the largest in the nation) of vacant repossessed homes owned by the Department of Housing and Urban Development (IrJD) . Many of these homes were severely vandalized, while others merely suffered from years of disrepair and neglect . Mr. Jaime Alvarez, a local contractor, played the major role in creating a pilot program which came to be known as the Acquisition, Rehabilication, and Resale (ARR) Affordable Homeownership program in the City of San Bernardino. The APR program was declared a model for the nation by H:UD Secretary Andrew Cuomo when he signed the Fa-pansion Resolution. It later received HUD Is prestigious John J. Gunther award, one of only two hundred to be bestowed in the entire country in 1998 . The goal of the program was clear, clean up the blight . However, it soon became evident that cleaning up the blight, albeit the primary concern, turned out to be but one part of the whole . Mr. Alvarez, along with his family, known as Alvarez and Associates, provided a vehicle for the communitY to clean, safe participate in a program that has created pride, jobs, affordable housing for the residents of the City of San Bernardino. Mr. Alvarez, s dedication to his family and community is commendable, and sincerely appreciated. V ry trul:;E�� Entered Into Rec. at MCC/CDC Mtg: "/�/// –ewis A g end tern No: �.-,,,,,,�Y,,,,(,,, Member of Congress by:JL:j cs City CIeNCDC Seas ary — City of San Bernardino - Uk-I—G7—'7( Wt—'l lid:�� t U:WUM-I L ur r :t-C I=L 4440.: MJ4 CI RNARDINO 300 NORTH STREET.SAN 9ERNARDINO,CALIFORNIA 02418 r n October 29, 1997 DAVID COERHELMAN Caundlman, Fouts Word (209)M-5175 The Honorable Bill Clinton President of the United States 'The White House 1600 Pennsylvania Avenue Washington, D.C. 20500 Dear President Clinton: I am a Councilman in the City of San Bernardino, Califcmia and have had the privilege of meeting you on two occasions when you visited our City. I, as well as the citizens of San Bernardino, deeply appreciate the attention you have shown our community with the community policing grants and the Defense Accounting Center at the former Norton Air Force Base. After suffering devastating economic setbacks over the past ten years, we are on the road to recovery and our progress has certainly been aided by your support. We have made tremendous progress in combating Might with the privately operated "Acquisition, Rehabilitation and Resale (A.R.R.) Program" pioneered in our community by Mr. Jaime Alvarez. However, we rued to sustain and expand our struggle against urban residential and commercial blight with the $15 million that has been designated for fighting blight in San Bernardino County. This money, which is contained in the recently passed Department of Housing and Urban Development budget, is essential to continue our fight against blight. The incorporation of the welfare-to-work model in our struggle against blight is innovative and can be used as an example throughout the United States. I urge you, Mr. President, to join the bipartisan efforts of Congressman George Brown, Congressman Jerry Lewis and the citizens of the City of San Bernardino by signing this important Legislature. I thank you, again, for all you have done for the City of San Bernardino. Sincerely, �Tft4 d DAVID OBERHELMAN Councilman, Fourth ward DO-3g 3 i October 22, 2001 Wells Fargo Home Mortgage, Inc. PO Box 1230 MAC #5403-012 Charlotte, NC 28201-1230 RE: Loan Number 5649671 To Whom It May Concern: On Saturday, October 20, my eleven year old son was shot in the backyard of my property. I am enclosing a copy of the police report. Fortunately, my son is alive. I regret to inform you that I have decided to abandon the property as soon as possible out of fear for the lives of my family. If necessary, I am willing to deed the property back to the bank. I cannot put my family's life in jeopardy any longer. If you have any questions, please call me at (909) 888-9789. Sincerely, Carolina Arzate ` cc: HUD City of San Bernardino - S Car Contain: 1.c.M. Follow-up «.p.a ❑ SAN BERNARDINO POLICE DEPARTMENT Wrenn ❑ owsm. ❑ CAD361000 � t I Eid'"" ❑ C.0 710 North 'Street(P.O.Box 1559) cv ❑ rco�" ❑ U San Bernardino,CA 92401{909)384-5742 Llu�fl M Ooorw,q ♦Jil as \ ).�• r a l 5 w �W(o 'ST 03 (c-z - I 12fp r✓ - I A C— t a14 S (c42Q A6 '1;. IX tw.F..trw.lt+.c a.i trwl 14 h- a Aq. a twa a mr� a c.w ��. LLJrwA�ol c1l ft l�AJ i o KI 67 �G+ � CA ci 2.41/ u, a Zp �.>,. n try rt..k rm r.rl a a■ b x aP a ooa y n z ATE ,�� t= 3 S 2�-t�� — �p M L.--- 1 a� ch i w "—ft 1 (jp5 q U_). (a ti/ X A�w le..vr ar.r pY L La naraa -i xa...F.n.ar.Kwan t,fw R%.. JZLAV x x 0a�w xOr �a ;y n.aaar.w I�i.�o.l a..r °1 : < .Y. x.:.., .,;...-.'yr...,.,»:-,o,..x.:�•:t�� <�>:..3t�r^•.w rr•:�3r<xrn ..'r•��ea.+.��tt?ak:ate- ....:::: :rr.:..x�.ox:�x«m,�:w K�>».•,a.., tZR•'+.s`C,2�`Y•;:R.1^8:^2�.R•1R owytv�:4` V mA_C`3ry.;av». x l— i is .t.l)♦is i Ylt. Q TAH. M la■y i Wb atr O Ue. 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Twwm,ir,.QL� Y6ira" O 1 Frwa ❑ 0 Ffr�i�uFs.oEt yectimv„w■ pKkwo, - ❑ r lub...nee ❑ ! NoWwlwa-6.d 6L bnmwtv110 _ r.�rrrw J 1r..o..a...se ..-V / r..of v - ra..bet rr wt.AA.ASS aar nr.t.>..rn.aq r.�.or Savo an o•r SAN BERNARDINO POLICE DEPARTMENT Summary Continuation Sheet 1.vim...•�+.�ri a-Qr.(RlMWr R2 /QrtL- J' n T I 1 _ - - T� / - F -� , k Iq 7-7- t/ I i. i 1 -T L l�wry Q16�♦. �1r�1 �Oli��Mw��w►s�Lr��n��rrr N_coo Scwjk*AF"r-lw w cro a uu • POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC 246 - SHOOTING AT AN INHABITED DWELLING JOHNSON, FLORA 2060 WEST' I7TH STREET,. SAN BERNARDINO, CA 92411 (909) 887-6389 AS S IGNICENT: On 10-10-00, at 1911 hours, I was handling a domestic disturbance call in the 1500 block of North Hancock Street when OFFICER OUTLAW and I heard multiple j gunshots coming from a location northwest of where we were. OFFICER OUTLAW and I quickly terminated our investigation on Hancock Street, and we went westbound on 16th Street in an attempt to locate the source of the gunfire. INVESTIGATION j After initially hearing the gunfire, which as obviously coming from several different weapons, I believed that the gunshots were coming from due west of our location; so, I advised OFFICER OUTLAW to check northbound on California Street, and I would check the California Gardens area (area of Magnolia and Colorado) . OFFICER OUTLAW and I split up at 16th and California and began checking those respective areas, but we were soon advised by dispatch that reports of shots being fired were coming in from the 1900 and 2000 block of West 17th Street; so, we went to that location. r I arrived on scene to the front of 2060 West 17th Street at 1912 hours, and I immediately noticed numerous shell casings in the street to the front of 2060 and 2048 West 17th Street. I contacted the residents at 2060 and found that there were approximately 15 adults with 15 to 20 small children in and around that house. I had numerous subjects telling me that the house had just been shot. At which time my reserve partner, OFFICER ROWE, and I began quickly checking everyone for injuries and ensuring that there was no one hit by the gunfire. 6 After ensuring that none of the occupants of the house at 2060 West 17th Street had been hit by the gunfire or debris and no one was in need of medical aid, I then asked everyone to sit down in the living room and kitchen area of the house so that OFFICER ROWE and I could begin a systematic accounting of all of the occupants of the house when the shooting occurred. I was also advised by all of the adults in the house that all the children were accounted for, along with all of the adults who had been present in the house when the shooting occurred. 's. I determined that FLORA JOHNSON was the primary homeowner/resident at 2060 West 17th Street; so, I interviewed her first. MRS. JOHNSON told me that her date of birth was 10-26-33 and that she has lived on 17th Street for F. approximately 19 years, and her home phone number is 887-6389. i I E ZEIGLER/50115/10-11-00 DH/10-12-00 I: RECORDS USE ONLY REVIEWED BY: i E • POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PACE 2 PC 246 - SHOOTING AT AN INHABITED DWELLING JOHNSON, FLORA 2060 WEST 17TH STREET, SAN BERNARDINO, CA 92411 (909) 887-6389 MRS. JOHNSON told me that she was in the front bedroom of the house (southeast) when she heard gunfire and looked out through the bedroom window and saw two vehicles leaving eastbound on 17th Street. MRS. JOHNSON did not get a good look at either one of the vehicles, and she could not provide any further description of them nor could she identify or describe any of the occupants of either vehicle. LEONARD MEDINA (DOB: 1-1-53) also told me that he resides at 2060 West 17th Street, and he stated that he was in the same bedroom as FLORA JOHNSON when the shooting occurred. } MEDINA told me that he heard multiple shots being fired, and he looked out through the bedroom window, and he saw a white or tan full-sized Ford station wagon with wood paneling driving eastbound on 17th Street. MEDINA also saw a second, which he could describe only as a smaller, newer car, unknown color. MEDINA did not obtain the license plate of either vehicle nor did he get a good look at any of the occupants. MEDINA stated that he heard at ; least 20 shots being fired from several different types of weapons. t MICHAEL JOHNSON (DOB: 3-18-63) stated that he lives at 2060 West 17th Street, and he was in the front yard when the shooting occurred. He couldn' t provide any description of any of the suspects or any of the vehicles and stated only that he heard gunshots being fired. t TAi1MY L. JACKSON (DOB: 10-21-64) told me that she was in the back bedroom (northeast) when the shoots were fired, and she didn' t see anything, but she heard multiple shots being fired. ! "r SONYA L. MORRIS (DOB: 12-11-74) told me that she lives at 2060 West 17th Street, and she was in the living room when the shots were fired. She said s that she heard several gunshots, and she immediately went down to the floor j and didn' t see anything. MICHELLE JOHNSON (DOB: 3-18-63) was inside of the house when the shots were fired, and she did not see anything. JOHNSON said that she heard multiple t shots but didn't see either of the vehicles involved. ;f While I interviewed these individuals, OFFICER ROWE contacted the other r adults who were inside of the residence when the shooting occurred and } obtained statements from them. (Refer to ROWE's supplemental report. ) '. F After I had completed my interviews at 2060 West 17th Street, I then contacted the residents at 2048 West 17th Street. ZEIGLER/50115/10-11-00 DH/10-12-00 RECORDS USE ONLY REVIEWED BY: POLICE DEPARTMENT C,A0361000 2000-43857 PAGE 3 SAN BERNARDINO, CALIFORNIA PC 246 - SHOOTING AT AN INHABITED DWELLING JOHNSON, FLORA 2060 WEST 17TH STREET, SAN BERNARDINO, CA 92411 (909) 887-6389 At 2048 West 17th Street, I spoke with EFREN ARIAS (DOB: 9-22-75) . ARIAS told me that he lives at 2048 West 17th Street with his wife (EDNA ARIAS) and his daughter (CORINA ARIAS) . He said that they were, all three, in the living room of the residence when they heard gunshots being fired, and he and his wife and daughter went down to the floor to avoid being struck by any of the gunfire. ARIAS didn't see any of the vehicles that were involved but only heard multiple gunshots being fired. ARIAS showed me his Dodge pickup truck, which was park both iistdrivew y, and I could see that it had been struck twice by gun fender. I also located one bullet which was mostly intact and lying on the front porch of 2048 West 17th Street. Later, after an ID Technician had photographed the bullet in place on the porch, I recovered it and submitted it to the evidence locker. I found one bullet hole in the front of the house at 2048, and I checked the interior of the house and found that the bullet came through the front wall, just below the front living room window. It went into the couch, which was located on the south wall of the living room. It went through the couch and penetrated the wall on the east side of the living room. The bullet, itself, lodged somewhere inside of the wall, and I was unable to recover it. I 'also had an ID Technician photograph the damage to the interior of the residence and the damage to ARIAS's vehicle in the driveway. After ID had concluded their investigation at the scene and photographed all of the shell casings, I then had OFFICER ROWE recover all of the casings from the street, and they were later submitted to the evidence locker. (Refer to OFFICER ROWE's property report.) After completing my investigation at 2048 West 17th Street, I was instructed to recontact MRS. JOHNSON at 2060 and ask her for her permission to conduct a search of the residence for any firearms. I spoke with MRS. JOHNSON again, and I explained to her that we had reason to believe there were shots being fired from individuals around her residence, possibly at the vehicles, and I asked her if there were any firearms in the house. MRS. JOHNSON told me that there shouldn't be any firearms in her house, and she gave me verbal permission to conduct a search of the residence for any firearms. ZEIGLER/50115/10-11-00 DH/10-12-00 RECORDS USE ONLY REVIEWED BY: i POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 4 PC 246 - SHOOTING AT AN INHASITE0D DWELLING JOHNSON, FLORA 2060 WEST 17TH STREET, SAN BERNARDINO, CA 92411 (909) 887-6389. I i OFFICER ROWE and I conducted that search with the assistance of OFFICER SAVAGE and OFFICER RAY KING, but we failed to locate any firearms in the i residence or in the rear yard of the residence. We also obtained permission for each of the vehicles that were parked in the driveway and in the street to the front of 2060 but failed to locate any j firearms in those vehicles either. ADDITIONAL INFORMATION: i When OFFICER ROWE and I initially arrived on scene at 2060 West 17th Street, our primary concern at that point was to ensure that none of the suspects i involved in the shooting were still on scene and possibly armed. Our next concern was to attempt to locate and obtain treatment for any shooting victims. 1 While we were trying to control the scene and contact each of the 15-plus adults who were at that residence and the numerous children who were running around the residence, there was a white vehicle which was parked to the front of 2060 West 17th Street. When we arrived, that left, traveling westbound on 17th Street, then northbound on Colorado. I noticed the vehicle leave; however, I did not obtain the license plate of the vehicle nor did I see who the driver was. I later asked several of the people that I interviewed : inside of the residence if they knew who was driving that vehicle or who the vehicle belonged to, and everyone in and around the residence claimed that they did not see any vehicle nor did they know who was driving it. i i i i ZEIGLER/50115/10-11-00 DH/10-12-00 RECORDS USE ONLY REVIEWED BY: '. F POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING ADDITIONAL VICTIM: GARCIA, GIRLEAD (DOB: 8-13-62) 2036 W. 17TH STREET SAN BERNARDINO, CA 92411 887-8526 GARCIA was contacted, reference the fact that her residence at 2036 W. 17th had been struck by gunfire four times with shrapnel from one of the rounds that penetrated her house, being recovered inside her house. The following is a summary of her statement: GARCIA said that she was inside of her residence with her children and her father when they heard gunfire. She said they immediately hit the ground and believed that three to four rounds hit their house, although they heard approximately 20 . GARCIA said she did not see anything but did hear a car speed away. GARCIA had nothing further to add at the time of this report. i 1 I i K. SAVAGE/50235/ 10-11-00 RS/10-12-00 RECORDS USE ONLY REVIEWED BY: POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING ADDITIONAL VICTIM: LOZANO, RAFAEL (DOB: 1-4-29) 2036 W. 17TH STREET SAN BERNARDINO, CA 92411 (909) 887-8526 Through translation by his daughter GIRLEAD GARCIA (DOB: 8-13-62) , LOZANO told me that he heard gunfire and hit the floor of the residence but could not advise any further information. I G 1 uJ K. SAVAGE/50235/ 10-11-00 RS/10-12-00 i RECORDS USE ONLY REVIEWED BY: i . POLICE DEPARTh= CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 — SHOOTING OCCUPIED DWELLING i ADDITIONAL VICTIM• GARCIA, VANESSA ARLAB (DOB: 9-27-82) GARCIA told me that she was inside of her residence with her family when she heard gunfire. She said that she immediately laid down on the ground. I GARCIA said that she heard a vehicle speed away at a high rate of speed and was followed shortly thereafter by another vehicle, although she could not describe any further. GARCIA had nothing further to add. ii I t c a F i 1 t K. SAVAGE/50235/ 10-11-00 RS/10-12-00 RECORDS USE ONLY REVIEWED BY: f POLICE DEPARTM CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING j I I i i ADDITIONAL VICTIM: I GARCIA, EMANUEL (DOB: 5-28-85) ' EMANUEL told me that he was inside his house with his family and heard rapid � gunfire. He described it as "pop-pop-pop-pop-pop. " He said that he heard loud thuds and believed that they were rounds striking his house and that he and his family got on the floor so that they would not be hit. EMANUEL told me that he heard a car speed away, followed by another car but did not see anything. EMANUEL had nothing further to add at the time of this { report. i E i t C; } 1 t. C i 3 IY r. 7 L R• V �. iV 1JV l,l 1 K. SAVAGE/50235/ 10-11-00 RS/10-12-00 j RECORDS USE ONLY REVIEWED BY: POLICE DEPARTM CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING ADDITIONAL VICTIM• GARCIA, CARLOS ISRAEL (DOB: 10-12-89) i I This victim, as well as all of the victims, prior to this all live at the same address at 2036 W. 17th Street, San Bernardino, California, 92411, ! (909) 887-8526. ' CARLOS told me that he heard loud gunfire and laid down on the floor of his residence until he heard cars pulling away at a high rate of speed. He could not add any further information at the time of this report. Li IN 3 a f i t a I Li I. I K j'. ti i� i K. SAVAGE/50235/ 10-11-00 RS/10-12-00 RECORDS USE ONLY REVIEWED BY: I POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING ADDITIONAL VICTIM• OCHOA, CANDELARIO 30DINA (DOB: 2-2-59) 2026 W. 17TH STREET SAN BERNARDINO, CA 92411 880-4058 OCHOA owns vehicle California license plate #2WPV677 which was struck by gunfire to the front of his house with the rear hatch window being shot out. OCHOA said that he was inside his residence and heard gunfire and got on the floor with his wife ISABEL and then made sure that the two children were fine. He advised that CHRISTOPHER and JANICE MENDOZA were there. CHRISTOPHER' s date of birth is 3-19-95, and JANICE' s is 5-21-96 . He stated that he believed that there was no damage to his house, however. OCHOA said he saw a vehicle drive at a high rate of speed eastbound on 17th that appeared to be the vehicle that was shooting; however, it appeared to be shooting behind it at other vehicle which was chasing it. He described that as a black Blazer or Jimmy-type vehicle. He could not articulate anything further nor could he offer any further information. t f 1� i R. SAVAGE/50235/ 10-11-00 RS/10-12-00 RECORDS USE ONLY REVIEWED BY: 'r I. POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING ADDITIONAL VICTIM• r ARAGON, MARIA ISABEL (DOB: 5-31-69) She said she was inside her residence when she heard gunfire and got on the ground. She advised that her husband went out and told her that their truck had been hit and that the back window had been shot out. She said that her two children CHRISTOPHER and JANICE were fine. ARAGON could not advise any further information at the time of this report. i i I ! j N t r 4 e f' tCt F t I l T f f i I c: 1 1 E AVAGE/50235/ 10-11-00 RS/10-12-00 1 RECORDS USE ONLY REVIEWED By: ! E POLICE DEPARTXENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING i STATHMBNT OF WITNESS. HIGGINS, LEROY (DOB: 12-2-54) 2014 W. 17TH STREET SAN BERNARDINO, CA 92411 887-6559 He advised me that his house was not hit by any gunfire nor were any of his vehicles. He stated that he heard gunfire and got down on the ground until it passed. After it passed, he got up and checked the exterior of his house. MR. HIGGINS had nothing further to add at the time of this report. f I } s # t l h r r: t s 1 f t U i 'U J K. SAVAGE/50235/ 10-11-00 RS/10-12-00 RECORDS USE ONLY REVIEWED BY: t i t . POLICE DEPARTMENT CA0361000 2000-43857 SAN BERNARDINO, CALIFORNIA PAGE 1 PC246 - SHOOTING OCCUPIED DWELLING i STATEMENT OF WITNESS• i ADAMS, JOHN PRENTICE (DOB: 12-29-35) ' 2004 W. 17TH STREET SAN BERNARDINO, CA 92411 887-6933 He advised that he heard gunfire and got to the floor of his residence. After the gunfire passed, he went out to investigate to see if anyone, was 1 hurt and observed that there appeared to be no damage to his residence nor his vehicles. ADAMS could offer no further questions. i } s i t t t4t 1. 1' tt I t v E Z R i k i K. SAVAGE/50235/ 10-11-00 RS/10-12-00 RECORDS USE ONLY REVIEWED BY: f SAN BERNARDINO COUNTY TRANSITIONAL ASSISTANCE DEPARTMENT MEDICAL REPORT / REPORTE MEDICO REQUIRED FORM - NO SUBSTITUTE PERMITTED ❑GR ," I''S REPLY TO:l RESPONDS: ❑ 13M East Mt.View St. ❑ 10825 Arrow Route +`.!•l Barstow,CA 92311 Rancho Cucamonga,CA 91730 DATE ❑ 2040 W.Woodpine Ave. ❑ 2050 Massachusetts Ave. Cotton,CA 92324 San Bernardino,CA 92415 i ❑ 1585 E.Highland Ave. 11 494 North"E'St. WORKER NAME `' San Bernardino,CA 92415 San Bernardino,CA 92415 ❑ 7977 N.Sierra Ave. ❑ 12219 Second Ave. Fontana,CA 92335 Victorville,CA 92392.5771 WORKER# PHONE#(_`"i) 317' Li,i%'i ❑ 1300 Bailey Ave. ❑ 56357 Pima Trail Needles,CA 92363 Yucca Valley,CA 92284 CASE NUMBER { 13 1627 E.Holt Blvd. 13 73629 Sun Valley Dr. Ontario,CA 91764 Twentynine Palms,CA 2277 ❑ 1637 E.Holt Blvd. 13 10875 Rancho Road CASE NAME - ' { % Ontario,CA 91761 Adelanto,CA 92301 ❑ 96M Ninth Ave. Ej .881 W.Redlands Biv Hespena,CA 92345 , - Redlands,CA 92373-8009 MI)•Telephone Services For The Hearing Impaired-(909)386-9780 TDD-Service de Teldfono pare Sordos-(909)386-9780 PATIENT NAME i >r' DATE OF BIRTH I' hereby authorize Name Name of Physician/Hospital/Agency to release the information requested on this form to TAD. I also authorize TAD to release information to the Department of Rehabilitation and/or the Disability Evaluation Division. Signature - Date NOMBRE DEL PACIENTE FECHA DE NACIMIENTO Yo' autorizo a Nombre Nombre del Doctor/Hospital/Agencia dar informacion pedida en esta forma a TAD. Yo tambiin autorizo a TAD a dar informacion al Departamento de Rehabilitaci6n y/o a la Division de Evaluation de Incapacidad. Firma Fecha THIS SECTION MUST BE COMPLETED BY A PHYSICIAN,PSYCHIATRIST,PSYCHOLOGIST,OR AUTHORIZED PUBLIC HEALTH DEPT. MEDICAL PROFESSIONAL. ESTA SECCION TENDRA QUE SER COMPLETADA POR UN DOCTOR, PSIQUTATRA, PSICOLOGO, PROFESIONAL MEDICO AUTORIZADO POR EL DEPARTAMENTO DE SAL UD. INSTRUCTIONS: The individual named above claims to be incapacitated. This report should provide the TAD with an assessment of any verified physical or mental condition(s)which would prevent him/her from accepting and/or keeping employment. 1. Diagnosis and prognosis: J J t 2. Probable Duration of Incapacity: Please list estimated duration,not next return appointment. 0 Permanent ❑Temporary From To a. Are more tests necessary or a more comprehensive exam necessary before the degree and permanence of the incapacity can be determined. ❑Yes Q No If yes,what kind of tests/studies are needed: b. The following ancillary studies have been ordered: c. Referred to: for more comprehensive exam/follow-up. 3. Patient can perform some type of work: 13 Full-Time 13 Part-Time Q'No Work Limitations(Specify,if any) COMMENTS Doctor or Authorized Staff Member Signature Phone Date GR 61 (E/S) (12/05) DISTRIBUTION: 009/nal/White - TAD Canary - Doctor