Xiong (4) MARK A.KARNEX
ATTORNEY AT LAW
Saite�240
122] Nicollet Avent�e
Minncapo�is,MN 55403
612-338�3100
(rax)6�Z-338-3421
December 2,2013
RECEIVED
C�EC 0 2 2013
To:sanara �ITY CLERK
From: Mark A.Karnry
Re:Sandra
Enclosed is the the notice of claim form you requested.
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Nvy':'20%2Gl?/!�i�� ?2:wu °1d � F�Y ��, P. 00i
' N'OTICE 4F CLAIM FaRM to the City of Ssint Paul, M�nnesota
MiKnen,ra Smre S►otr+t*d66.DSsutles thnr"...<.�ery ptrsnn_..wRo clnimr�'n�a,eet jmin erty rr�unicip�llry„_sbell teu�s ro denresenlnllo rhe
governinq bndy vf rhe munitilwl�ry wirhi�lR0 days q(rer rAe alleRrd ro,rsor i,yury is disrnvered��rorire s�oring rhe�irne,plece,�n<!
GirC'�rn+stoaces lhCStof,Q�ul 1ht amo�w��f Cou�ft nsatioR or other hlief d�nrandeA."
Pleas�complete thi,c formi ia fiS ea6rery by clesrly typing or printla=youc aasr►er to eac!►question. T�raore space;s
ntedtd,s►ttrch�ddltional st�etts. k'lesse t�ote Wit you will not be contacted by telephonc to cLnrf#y nnswers,so�rovide ss
nnuch tntormatloa as necasary to cxp�am yonr daim,end tE�e amourrt of compensation#eing reqacsted. 'kou wN receive a
written acla�owledgetreetit once your for�is receoved. The procesF can tpke�cp to ten weeks or lare�er dependfing oa the
nptor�o�yoR�diltr�+. �'his fo1�tnbl+[De si�»ed,9M Lot1t yst�cs cOmpltted. I£5omeching doei not app1Y'�wn'te'N/A'.
SEND CONI�'LE1'ED�4�AND OTI�ER riOCLTMENTS TO: CITY CLERK,
X5 WEST KELX,OGG B�,'VD,310 CX'1'Y HALL,SAINT F,A�UL,MN 55102
Firsc Name ��v Midflle lniaal Lflsc Name ��S��'1� —____r�,�..,��v E D
Company or Busin�ss Namc � 2��3
Are You an Jnsurance Comp�ny? Y�s No If Yes,Clain'►Number?
StreetAddress�� �`�dSe� rQ v �ITY CLERK
City ��7 ��.C�1 State �``� tip Code 5� �
Daycime T"hone �-�� Cell Phone(,� Bvening Telephone(,.,__) -
Date of Accident/Injwry or i�ate l�iscovered. � �� Time ��•3� atr� m
Ple�se state.in detnil,wh�t occurred(happenedl),and w}i,y you tue submitting�ctaim.Please indicate wAy or how you
feel the�ty of Sain[Pavl or iu employees are involvcd andJor responsible for y0ur d�mages.
n P.IYI�
r. 0,�11 � �R.� w
�Pl s�e chrck'tlye box(es)that most clostly represent the reason for complecing this forrn:
y vehicle wa,s dazr�ged in an necideet ❑My vehicle was d�maged during o tow
My vehiele was damaged by a pothole or eondicion of the meot ❑My vehicle wns damaged by a plaw
L?My vehicle was wrongfully towed and/or ticketed O I was iajured or►City prope:ty �
�Other type of propercy dama;e—please specify
❑Othet type of injury—ptcese specify i
In order co process your claim you n to iac�ude coates of all avalicsb3e documer�ts.
PoC the Clairns�ypcs li9ted below,please bG surs to include tbe docurta�n�s indicated o�St will delay th�6andlit�oF
your claim. Documents WILL 1�IOT be�ceturned and become tbo pr.operty of the City. Yora ane encouragnd to k��p a
copy for yourstlf before submicting your cla�m form.
O�operty damage cls�ims to a v�hicle:two escimates fer c1►e repdirs to your vehicle if[hs darnage exceeds
�500,00;or the actual 6�11s and/or receipu for the repairs
O xowing claim�s:legjble oopies of sny ricket issued as�d s copy of thc impoua�d]ot rec�ipt
O Other propetty darnd�e claims:cwo rcpair estim�tas if the damage�xccods SS00.00;or thc actual laills
md/or tecoipts for the repairs;detailed list o�'damiged it�ms
O IeY�uy claims:medieal bills,reeeapts
O Phocographs are always welcomc to documcnt and sup�port your ctaim but will no�be�tuzned.
1'a�e 1 of 2�Plea9e compLete snd return both pages oiClaim k'ortno
H0+/2GI�p;3/WED 1�:41 PY FaY �I�. P. G03
� k'vilure tu C�mplete 9u►d e¢Wrn both ps�cs will resutt in del�ty i�tbe handling of your���.
i
All Clrims—nlease cc►�,np,�gjg is_ tionD
Wtre the.ce witn�sses to the incident? Xes No Unkaown (circle �1
Ptovide the;r nAmes,<<dd�esses�nd ce�ephor�e numbess; _
Were the po3ice or 13w enfnrCCment ca11e 1 Xes No Unkr�own (circ )
If yes,what depamn�nc or:�oency? �• Caae#or repor'�# �
Whetc did the actident or injary t�lce pl�ce? 1'rovide scrcet address,cross s�iatersecdva,aame of park or ftx:ility,
close t la dm�rk, ec_ Pl�nse e as detailed As�0 �ib�G Yf n CSSEIIy,att�ch n diagram_
v� � � ��� �v --
, .�. - �� N e,--,e-
°lease i�dicute thc�rnount you�se se�lung i»com�ensation oT what you wonld}ike che City to do to resolve this claim
tp y0ur sDtisf�cQon,
V ic e w � e $ Cl chES section d
Your Vehicle: Year__ Make Mode r
Licen�e Plate Number_� Sca�e Color
Registe�d�w'ncr
Dtive�of Vehicle t�
Area Aam re l � e
Ci�y V�hicle: Y�ar �1 ]vk�nlce Tt•, Moac
L�cense Pl<1te Number �9" State�CoiQr
Uciver of Vehicic(City� loyee's Name),,,_ ��
Area Damugcd
Och is � ' >>d
]n' �im — com ICCo th 'o M �
How were you injured'? ,
What p�n(s)of yonx bod were injured? ` �
m
F�i:►va you�eupht medical tr�atment? � es� I�o ,Planning to Scck Treatment(arcit)
Wben did you receive tr�:��ment' � (pro�de d�te(s))
Na�ne of NEediaai rrovider(s); �' t�"
�d�� � - t.l Telnphonz
Did you m�ss work:ls a result of your iRiun? Y es vo
(prnvide date(s)?
When did you misS work? '-
Name of your Ers�ploywr. Tclepl�one
Address .
Cl C1�ecEc�6erc if yuu 9re attactring more pages to�is cfaim form- Number of�adi�nonal ps�g�
,�y signing this,forn=,yon cere startz►ig tlsai ull�information you 1eAve provided is rrue and correct to tlae b�st
nf yocv beowledge. Unsigned forms will not be,�rocessed
Sil��lt�n$Q��'e CIQ.iI►i can rBSult eR pTPSeCitt�Ori. �tr form was complr.tcd
Print the N���e of tT�Person who Com�leted tt�is Forxi2= ��U 'v
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Si�ltature ot Pe�on Ma6cing t�e Claim: DV�
Reyc��a�cnn�Lry ao i r