Vantassell NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Mi�inesota State Statute 466.05 states that"...every pet:son...who claims damages from any municipality...shall cause to be presenred to the
governing body of the municipalit��within 180 day.r afier the alleged loss or injurv is discovered a notice stating the time,place,and
circumstances thereof and the amnunt o,f'compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. �
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
� 15 WEST KELLOGG BLVD, 310 C�TY HALL,SAINT PAUL, MN 55102
First Name -,���t�� �� A. Middle Initial� Last Name � '�.►'"l (C� � S�` �
Com an or Business Name '��_ R EC E I V��
_ _ _R_Y -�--- - ---..___ _�_ --______ _--- _ _. ____ _ _
Are You an Insurance Company? Yes/No If Yes,Claim Number? NO-V �5 ���
Street Address \ ("`�E � r� -�S�� � f � �'�T� ���
a ■ s �
City �� -� C��,�-�-� State �� f1 Zip Code��?
Daytime Phon��)���c� � 7 Cell Phone ( ) - Evening Telephone( -�C`-=�v`�—
Date of Accident/Injury or Date Discovered ��'� � S�� � 1 � Tune �°�`-���c� am/pm.
Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are mvolved and/or res nsible for your damages.
�- � - i �o cn "` ` 7 c� �-ti%�d t ° � ,�� , �% ,�-;.�
i
• ,, � �} � - � , �� � �
�^ •-'u' f3.�o ��p rl _�-.F�T--� � '�-L-�� fst�� � C�
Please check the box(es)that most closely represent the r ason for completing this form:
❑ My vehicle was damaged in an accident �� ❑My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street � My vehicle was damaged by a plow
C�My v�hrcle was wrongfully towed and/or ticketed �was injuied on City progerty
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
1n order to process your claim You need to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the�damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list of daznaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be retumed.
Page 1 of 2—Please complete and return both pages of+Claim Form
'J� G ��-�2� � o�vv�-� �.�" '''"�,/ � a f�S
Failure to complete and return both pages wili result in delay in the handling of your claim.
All Claims=please comulete this section
Were there witnesses to the incident? Yes No Unknown (circle) _
Prc�vid�t�eir names,address�and tg�phc��numbPrs: - —
Were the police or law enforcement alled? Yes No Unknown (circle)
If ycs,what department or agency? , ; - ��Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
dosest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. �3 p L ���<< �_q�
' 4 `
Please indicate the amount you are seeking in compensation or what you would like the Ciry to do to resolve this claim
to your satisfaction.
r� r.� F�,� r� � �' � rj. �i� �' �C ( c. b -�- �.l l �{ =c.-�.,v.r Joh.s
Velucle Claims ulease c�-----omUTete t�fi'is secbon----T� --- ---�c�eck�iox-i�"t�i'is sec ion oes n --- "-
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged l
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this section ❑ checkbox if this section does not a I
How were you in'ured? � � /� I� � � d' i � M.�-c���1 ntp f3�r-o k �
. � �
What part(s)of your body w re in�ured?
rt
Have you sought medical treatment? es No ' F Planning to Seek Treatment(circle)
When did you receive treatment? ��1.'n� �°�, N b 5�-`►-�r'� (provide date(s))
Name of Medical Provider(s): S` �r�'� � �
Address S � Telephone
Did you miss work as a result of your injury? Yes o
When did you miss work? �`E' k' G � � � (provide date(s)1
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all inforntation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
� j .� jc� _ (3
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed this Form: �C� �� f'r'A V� < <'�'t'-�--
Signature of Person Mal�ing the Claim:_ ...��k%�n,.����`A �A � o �U '
Revised February 20l 1