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Gaber NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that °...every person...who claims damages fram any municipaliry...shall cause to be presented to the d�verneng ouuy u�u2e munuipuury wunin i ov uuys a�ier rne uuegeu ioss or�n�ury is uiscoverea a notice stating tne ume,ptace,ana circumstances thereof,and the amount of 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 mach mtormation as necessary to explain your claim,and the amount of compensation being requested. You will receive a wriuen aclmowledgement once your form is received. The process can take up to ten weeks or longer depending on the natnre of yoar daim. 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 KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,MN 55102 , � First tiarn�j�� Middle Initial_'�Last Name L '�L�'�i\ Company or Business Name /v � �'��`!��V E D Are You an Insurance Company? Yes�ff Yes,Cla�im Number? ��N 1� Z��F Street Address j � � � J� � 7�' � k �� 'V r-v:-��CLERK 1 � "�, �. �- Ciry �- V � �- �\ � State .�'r1 � Zip Code ? �" � r� � Daytime Phone(�i )��--l.�j I Cell Phone('2��-�.��- s�7`1ZEvening Telephone(;��)��-'- y 7`t Date of Accident/Injury or Date Discovered ��- �/ � Time /✓� 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 involved and/or responsible for your damages. 1'� �� -��'k� �=%�':L �,:�% #�' � �� ►�L` E 3" `�Z �� %.�� lo :4.�� y✓. �1� T ✓�.�%�' ;1/�/« � v+�'�j ��i�(L �j�a� �iM�/ �/{� "1 h,�T ��J� 7_ �T cJ4.r �i%= �/' =�';/G)�`c c/ + I.�P�✓�ic� 1.�' C��7p7'Cc� ,,> 1 L� A/♦ !►��{J'f�C_ 6.,.` >j-. ��,.<�l✓.r � �� 1 L'4/��L'{ y//1'�C?ril�i�l � •(1',l� 'L� �j� �1a'r 7�C iL- IrL'"'/ s� � . , „ � �. � i� ♦ '►� � r'L� � /�� ''✓i�,+ ��y: �!:ycv l�' L�' � �`+-Mc`i-1 !'� .i �►�l i�T �, I�—.Z�l `'I �.l�µ � �'G' :'�C"c� . � ;� � ..�• �. �' 'jMC� G.��C�,� '-1�d � � �i E�''`{' 1`'1� L,l'E�.�,�T i.I n/ `t-./ A`l �'/•'�/"l� b� � G-1�^Fr' 'r��r�' ?�►�+/r� �lc��f: Please check the box(es)that most closely represent the reason for completing this form: �Mv��ehicle was damaged in an accident ❑ My vehicle was damaged during a tow � �i} �ehicle w�as damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow O My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property O Otber type of property damage-please specify a/� ❑Other type of injury-please specify iv"�� In 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 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 Yriotographs 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? Yes No Unknown (circle) Provide their names,addresses and telephone numbers:�� Were the police or law enforcement called? Yes No Unknown (circle If yes,what department or agency? i►/L� Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark, etc. Please be as detailed as possible. If necessary,attach a diagram. � /f� Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. � u%='c��a ��`KC T�i! �--�l� j�' S�s�' �� { ��'-L' �� „ {'.�ie�(G!!/ ' S�� id�%i>��J Ti�1;�,y� i�p/ �-;�',` ��4� /1 i �4i//'T r1�`'.1� � ,_i:l�'��,.f ��rL/ [ Velucie Claims- lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year :3��`�l'� ' Make (��'✓'��- Model � . ��- T.ir.en�e Plate Numher ��k S.�� State '�Color�(��_-r� Registered Owner ��4��4� r�i�I I�-✓ � '��:' � Driver of Vehicle `Y'►��''y,4 ��y (�.4 i��`-� Area Damaged �� 5�c%✓�"� ��`�:"� City Vehicle: Year �/4 Make ;✓� Model ,.,/q License Plate Number .✓/� State .✓/+ Color iv'f� Driver of Vehicle(City Employee's Name) .✓� Area Damaged i✓A In' Claims- lease com lete this section ❑check box if this section does not a 1 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? 9�" (provide date(s)) Name of Medical Provider(s):_�n/' !f Address �/ .�+ Telephone �!' ,� Did �ou miss work as a result of your injury? Yes No When did you miss work? /✓ � (provide date(s)) Name of your Employer: �,�T_ Address _�G� 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 oJ your knowledge. Unstgned Jornts wt[[not be prOCessed. Submitting a false claim can result in prosecution. Date form was completed � �r��.�� Print the Name of the Person who Completed this Form: I�J�� '�� Signature of Person Maldng the Claim: �%' 'L-�� /�'�'l/'�`J� i��./r l Revised February ZO11 _ _ ,. . e.,. . .. _ �, - .. r �.. - �• �,�.� � x. . + , �� . .. '>i., . .' . q = ., �., F tC_ .. ,:a�, . �� .#_��. . . __m. ._.. . a �. rk � �.., ,. .. . . . . ._ . g��,� STATE OF MINNESOTA � 4� � �. �� _�� :�� CERTIFICATE OF LIEN RELEASE � A�$ ' -�:",: � � �� : � TO A MOTOR VEHICLE �a � �� a�{,��.� �.�f � ;,d � :. � �� ' This security interes " hereby released on �� - , � ��. �;�,. � a e ��; �- � � �,. ,�� X ,_ / � �� ,l �� ,�, Signature of Auth ized Agent Title � �� 'f.l"/��TG"/��/�,��-7-��' �C'�"L �� IMPORTANT - DO NOT DESTROY � �� This Certificate of Lien Release must be attached to the � �� .,� �� original Certificate of Title to e,stablish clear ownership. �� , �� k�� s�� ,< :�'a� r€ i�* "�i�?.r '� a w��`� ��.��`�-� ap�".s�'�'�. �, a , ��a�-�.3 u;,s,��•m.��,� es�,� a.�e:� ,e e v . . . ,?��r� ,� ,,��n� � � �a��a�� Minnesota Department of Public Safety Pre-Sorted Driver and Vehicle Services 445 Minnesota St, St Paul, MN 55101 First-Class Mail L'.S.POST.�GE Web: www.mndriveinfo.org Phone: 651.297.2126 P.�ID TTY for hearing impaired customers: 651.282.6555 Permit�o. 171 St Paul.�f\ Certificate of Lien Perfection PS2701-08 Retain this document—See reverse side of this form for removing this lien. Plate No. Make Titl�No. y� TICJ205 HOND G0870V090 2HGFG12696H579525 Model Yr. Model ��h�� 06 CPUCL 12/O1/10 LIEN HOLDER 1 ST S ECU RE D PARTY GABER BRENT AItE.'V 11429 2707H AVE SW EUCLIDNW 56722 (��u��u�i��nn��n��i�n�� 720 Pl xss:AUTO='ALL fOR/1ADC 580 BURLINGT'ON NORTHERN FL-DERAL CREOIT UNION 3030 DEMERS AVE GRAND FORKS NO 58201-4057