Bland Williams NOTICE �F CLAIM F4RM to the City of Sainf Paul, Minnesota
:bfiru�esan Stutc�5iaru�e d66.U5 s�nte,th�r� "._.eve�w�per:cr�n...tirhr�rlarniti.rtanrnges,fi�om am=»tttl!/CIp!llfJ.y...sh�il!catrse ro 6e presented tv dre
g�renrrn,g bo�1y�,/'rhe mu�ricipality Frirhin/8f1 dci}s qJie�r the nlA�geil tos�or i�jury is drscvvered a�roliCC slalur�t/re trnte,plcrce,rrxd
circrrmsrrrrrce.s�here�j,�ind�lrc anrnu�rnnf coinpelisa�ion nr otlrer reltef denrmadcrL"
P�ease camp[ete this�form in its entiret��hti�cicarl�typi�or printing your ans�vcr to each question. If more space is
needed,attach additional sheets. Pteasc note that}ou ms,y or may not be contactesi b,y telephone to discuss your claim
circ«rnstances,so provide as mucli information as neeessar,y tn explain your claim,and the amount of compensation being
reyucstcd. This forni mast be signed,and both pages completeti. If sumething does not appiy,write°n/A'.
SEND CD:�IFLETED FORRI AnD 4THER DOCU1VIEl�'TS TQ:
CITI` CLERK, 15 ��EST KELLQGG SLVD,314 CI?Y HALL, SAI�IT PAUL,NIl� SS1U2
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First Naine L�,r�V�.-�''j��, Middle Initial� Last Narrie � ��l; �� ��,(�I(X�YYIS
Campany or Bu.Siness Naine, if applicabie
Street Address� ��..-� �� ��✓'�� �� , l Q �
�'ity ���t��� �U,-'l�� State ��N � � Zip Code c�l C��,
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Daytitne Telephone(�� �4�2'���' �I� Euening Telephone{�� � 1 �r�� �{7
Date of Accidentl Injury or Date Discovered L'�' 2� -��,�_'�j Time � am; m circle)
Please state, in detaii, �vhat occurred, and why yon are submitting a claim. Please indicate why or how you
fccl tl�e City of Saint Pau1 or its cmployees are involveti ancUvr responsible. ,
t��1 ����z.,i1 ��S ���- ��,�r F. V1� rv�o c� cx v�c� O � � �A�jC���,�,T_
G�,tict c A,�,v�;� � �1 zs�r-� cpc� �-�i"i �ct v-- c)+`� -�,� a t 1 �c..�,�t'Cx v-v�� i,:i .
S ���✓\ T d�'I_��;� �-E-.—(":[-�F --�-L� f e�-t- t'v�� �vt�c v�� ��i►.��2c4 �,nc�k �—�-
�r��S-e.._ ��� �MT r�..�,� �1�3G�..'�A�nn.A.�� S btv-'t- c�.0�v�1 �_._�e�C�S ll�_
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'Y� � � � �V �- 1C . - � i'}� "` �,
Please chcck the box(es)that most closely represent the reasQn far cor�zpletin�this form;
❑ Vehicle was damaged in an accident �Vehicle�iras damaged during a tow
O Vehicle was damaged by a pothole or condition of the street ❑ Vehicle�Tas damaged by a plow
O Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
� Other type�f property damage-please spccify
❑ Other type of injury--please specify
❑ Other type not listed—ple�se specify
In arder to process yaur c�aim voa need to incluae caaies of al!applicable documents. This is a general
guideline�f what should be submitted rvith a claim form, but it is not ail inclusive_ Yon may be askcd to
provide additionaI information depending on your elaim.
O Property damage claims to a vehicle: at least twa estimates for the repairs ta your vehicle;ar the
actual bi]]s and/or reccipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Othcr praperty damage:repair estimat�es, detailed list of damaged items
O Injury ciaims: medical bills,receipts R E C E I VE D
O Photographs can be provided but will noC be returned.
Page 1 of 2-Please complete and return both pages'of Claim Form �AN 101014
Failure to providc a completed clairn form tivill result in dela�js in process�TY CLERK
No6ce of Claim Form,City of Saint Paul,pagc t�vo
AIl Claims—please comuletc Ehis section
Were therc wifiesses to the incident? � Nv Unknown (circle)
lf yes,please prouide their names, addresses and telepl�one num6ers:
/��! �1�.Gt�v�-� � v�a, �I�-t,\! � L�V j� �
Were the police or la�v enforcement called? Yes No` Unknown (circic)
If yes,what department ar a�ency? �� � 1-� Case�or report#
Where did the accident or injury take place? Provide street address, cross street,intersection,name nf park
or facility, closest landmark, etc. Plcase be as detailed as possible. If helpful, attach a diagram.
N i !k � �
Please indicate the amount y�u are seeking in coinpensation fram tilis claim or vwhat you��ould like the Gity
tv da to resolve this Glaim to y0ur satisfaction. �I C��c^ ,� t �l � j ;�v��l c c,�r �� x.��,�
— -`r C�- ..o . � c�.V— � l�n � �v� 'C l,, w� � C 0.'� W r .-�-1� , l o P�a 1 cP
K�� C' Gt r ..�c:'S r�n i.J P � 1 I �-N --}�n 0.� �{'�P " � Y �
Vehicle Clairns— lease com lete this sectian ❑ check box if this section does not a 1
Your Vehicle: Year �� Makc Model e� � C �
License Plate Number M e Mp'��'� State V�� Color G�-e,e�
Registered Owner �.�.�,w�z.fi;�c�
D��iver c�f Vehicle �,�:.,w�.e�h,;c�
Area Darna�;ed �7-a-L�z,,- --�h e �u r- o� f �a vt �
Cit��Vehicic: �'ear Make �Iod�l
License Piate Numbcr __ _State_ CQlor
Driver of Vehicic(City Empl4yee's Name)
. Area Damagcd
Iniunj Claims—piease comnlete this section �check box if this section d,oes nof annlv
Ho«�.v�re yau �n�u.red?
What pari(s}of your body tvere injured?
Have yau sought medicai treafi�nent? Yes No Planning to Seek Treatmcnt {circle)
t��en did you receivetreatment? (provide date{s))
?�Iame of Medical Provider(s):
Address Tetepi�one
Did you miss work as a result of your injury? Yes ��o
When did}�ou miss wark? (provide date{s))
Name of yoar Employer:
Adc�ress Telephone
[7 Check here if you are attaching more pages to#his cl�im form. �Tumber of additional pages
B}�cignrng tlrfs form,�otr are statirtg�hat al!infnrntal[o�r j�ou have prot�itled is true and c�rrrct to/he besr of ynur knorvler/g� Unsin�red
fnrms will naf he�►ocessed. Strbmiftin�a false c/ai�n can resr�It 7n proserutiuR.
Print thc 1�'ame af the Person who Completed this orm: C-�w�-�--�- c.� �1� / � C,� �S
Signature of Person Nlaking the Claim:
Date form�vas completed Re,,;A�a e,n,;��nm