Feng NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesora State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
goi�erning body of the municipality within I80 days afzer the alleged loss or injury i,s discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Ptease 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 inforination as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written aclmowledgement 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 dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELL4GG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name C In e- ka✓� �M��c�C,�� �Middle Initial Last Name �e v�A Q��`�IVED
Company or Business Name 2��3
Are You an Insurance Company? Yes/N9 If Yes,Claim Number?
StreetAddress �Z�� �i�Y�� ��KC �,���C�2 ERK
City �Yde� ����S State � Iv Zip Code �� �� Z
Daytime Phone( ) - Cell Phone(6 S� )2��- ���� Evening Telephone(_) -
Date of AccidenU Injury or Date Discovered �e�fe►v��er ��I �ZQ l� T�e I 1 �o� ��
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 involved and/or responsible for your damages. A�- QYO�„d
i� yn� o� �I�� t��� I, -{�;,�d �, cz�� �q S S t�q►�h t Psf Ate
�nd Te��lfo�la I ,,� `re- l�a�( . Z �e t e vf-(�'ce�- �,.itt� �.r,y �y fB�wc�,r.!o�
QvtC( �,./ai fo�C� � w,7��C� be ✓lot���ec� ',f fhe Crt✓ woiS re�o�erec(. Q„� ��/o3/Z�/3�
Z p��oc.cl� G�, o{�{.�lev ol-, ►v�Y owvi qSK',Nq �`.w, t� in.y �v was veco�t*�d.
T�IP 4eDOr{ cA',d ,-f wqS ✓2covQrec,� 0� �lZ° /10►�{ 'f{-Q. ✓IZXt c�ay Wjy �Av wqS
S-Eoleh. ��f Z �.✓a5 �evc� hot��.Pd. � hac) �� �A� 9��F�76 �� tow av�d �,t��9e
C�iG� 2 -P� ret��e�c Wty S'f0�8vi (i��t: cl� -
Pleas�check the box(es)that most closely represent the reason 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
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
C�Other type of property damage–please specify M� �eln;�k �as �-tal{h� c�t-� f�',Ip�� {� �a�ta�� w.e w�^e� "'e�O��'��
❑ Other type of injury–please specify W���g��Ily c Ina•ycd �o v ��e w
�— A�el St'o�AO��e
In order to process your claim vou need to include copies of all applicable documents. .�PQ
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.L 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 damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2–Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comnlete this section
Were there witnesses to the incident? Ye No Unknown (circle)
Provide their names, addresses and telephone numbers: � v o� ��°`� � ��° � 9 7�
�l S° Jeff-e v S o✓► C�o w,w,�H S C i � �-f. �a v � M�J �j ! I
Were the police or law enforcement called? Ye No Unknown (circle)
If yes,what department or agency? �f. �v� �n�� [� Case#or report# (3L 4�i� 0�
Where did the accident or injury take place? Provide streell address,cross street,intersection,name of ark or facility,
closest landmark,etc. Please be as detailed as possible. IP necessary1,�attach a diac�gram. �� ��e �"�"'�f�q h
0'� V�eS��f� Alnc� ��✓✓����G r�oi � � :h Lif• �'NV� �i 7 �1�' .
Please indicate the amount you are seekin in compensation or what you would like the City to do to esolve this claim
to your satisfaction. Z �ovld ; e o he �ovh -p^^ S��'ed 'N'�t� f�e
q �h� a �- 4��.� b
Vehicle Claims- lease com lete this sec�on ❑ check box if this section does not a 1
Your Vehicle: Year I q°�Z- Make Ho�dq Model ��<< At��^ ��
License Plate Number $LS M J� State M I�/ Color C�vee�
Registered Owner C�t4- �/,v��,q Fen q
Driver of Vehicle N/P
Area Damaged /�l/14
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims-please complete this section I�check box if this section does not annlv
How were you injured?
What part(s}of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
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 information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �� � �� � Z°� �
Print the Name of the Person who Completed this Form: C�1 e- t`�G�►q ���19
Signature of Person Making the Claim: �
Revised February 2011
Pride, Professionalism & Partnership
JOE SANDQUIST �� � � � � �'
Officer
� POLICE DEPARTMENT
CITY OF SAINT PAUL
- 367 Croi�e Street l�oire Mail:651-266-9000 ext 71869
�'Peoteau� Sain[Paul.MN 5510! jos�h.sandquist@ci.stpau/.mn.us
� CN# �� ��°� �L��
If you have ques[ioos regarding your report,call:
Saint Paul Police Records Unit (651)266-5700
O
If you have a comment or concern about[he service you
have received,you may report it to the St. Paul Police
Department, the Civilian Internal Affairs Review
Commission, or one of the organizations listed below:
Police Civilian Int.Affairs Review Comm. (651) 266-5583
St. Paul Police Department Int.Affairs (651) 266-5760
NAACP (651) 649-0520
Urba� League (651) 224-5771
Council on Asian-Pacific Minnesotans (651)296-0538
Council on Hearing Impaired (651)297-7305
Indian Affairs Council (651) 296-0132
Human Rights (6511 266-8964
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