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Fellman NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Mi�rnesotn S�ate Statute 466.05 stntes thnt "...every persnn...wF�n clnims dmm�ges./rom n►tv municipnliry...slTall cnuse�o be presented to d�e ,(n��erning/�ody of tlte nutnicipa(iN withi�[ /80 dctvs after t/ie nlle�et�/oss or injury is discorered n notice stnting t/�e time,p/nce,aird circunrstcrirces tl�ereof,and dre amount nf compensntinn or other relief deut�nded." 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 th:�t you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and�he amount of compensation being requested. You will receive a written acknowledgement once your form is received. T e 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 CITY HALL, SAINT PAUL, MN 55102 ;'� � 1 First Name �.�C F'C 1 C � Middle Initial�.,� Last Name � C' � � ►�Y �C�� r 1 �?�(`G�v�D Company or Butiiness Name ��,�—d8 Z�'�4 ii\ N Are You an Insurance Company? Yes/ 10 If Yes, Claim Number? LERK Street Address ��C� � ��t 1 KC ��' , City �� i�l l� State � ��-�% Zip Code J� � �.(`3 Daytime Phone (6� f),�� C1�11 Phone ( ) - Evening Telephone(� `'� )��` � � Date of Accident/Injury or Date Discovered ��—�l �� ' ��'1� Time • _.� � �� am/��m) \.J 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. � � `� ' • "�l� ;(' � C- . i ., � ' -- -�`1�--ca� � �; } ca _ � Please check the box(es)that most closely represent the keason 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 ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim you need to include copies of all anplicabte 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 WTLL 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 i sued and a copy of the impound lot receipt O Other property damage claims: two repair es�imates if the damage exceeds $500.00; or the actual bills and/or receipts for the replirs; 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 I+ailure to complete and return both pages will result in delay in the handling of your claim. All Claims—pleasc comn�ete 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? ��Ye� No Unknown (circle) � :J�, , ..,�� -, � .� If yes, what department or agency?,� l c.,i��'�i�„� '.r� Case#or repart# �.;•�Z�_ 1(.� �.� �,�-�7�3 ��r' �l�� -�-�i�.C��`� W here di d t he acci dent or injury ta ke p lace?�rovi de�treet a d dress,cross street, intersection, na� e o f par k or faci lity, closest landmark, etc. Please be as deta led as possible. If necessary, attach a diagram. t �'`N�,S —SC7L� 1 .��.�' t�` .:3c-�� ►k� � n��c,-�cz`�'C"`�, � Please indicate the a. ount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction.�� `;`�� Vehicl� Claims— l�;ase�c�m tc�t�this section - -�Lh ck box if thissection does noi a l Your Vehicle: Year Make Model � License Plate Number,�(1� L�� State�.�Color� I�� Registered Owner �Y" "' _ L - i'11 Driver of Vehicle 1�C�i' F�� Area Damaged /;�/�t 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 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? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No _�h�rz r_lid y9ii miss �u9rk2--__ -- —-- __ _ _ --------- —- �Pro��;late(s}}. _ Name of your Employer: Address Telephone .r-� �Check here if you are attaching more pages to this claim form. Number of additional pabes �rr By signing this form,yoic are stating tltat ull informatiorc you laave provided is trice and correct to tlze best of your knowledge. Unsig�ted forms will not be processed. / � Submitting a false claim can result in prosecution. Date form was completed / �� / ��f�� —T---- ! , Print the Name of the Person who Completed tpis Form: [_:. , � �' G�. � �(� / �� , _ ,. Signature of Person Making the Claim: '� ��-r'.�. � �f �- ,.... ___ Revised Febru:try 201 I ..��+..�....:a Ramsey District Court RECEIPT Date/Time: 1/27/2014 12:00:10 Defendant: FELLMAN, GREGORY CHARLES Receipt No.: 2150939 Payor: EDNA TRAHAN Location Paid: MAPLEWOOD Citations: 620900203723 Amount: j 17A0 Amount to Be Refunded: 0.00 Totat Amount Paid: 17.00 Method of Payment: VISA Check Number: Comment: � j . �S�RIG� W 5R E �E� Q1 G g��►Q 5�1�2 15 KE�P��' �g`�� S�IN��,5�.'2�'�'r 001134069950 956�164 ZER�N��;� �QC11A1t\ c,�PEO VI��991 E'�Q�'��'� �� , �E It�U� 0�.� 1� Q�08D��bn 11, �4 4At CN:609U1 p��N'4�6�,9 &�� 1�w�0 ��pl EpNA 0 tQANAN (� C�510M��COPy at_.-/��(}� �' , � �c�u� � , . , � ; �c� �� - � � ��-- ��.u�� - �� f �- ��d �-� �� . ��-�- �}-�� -�-� �� KEEP THIS COPY FOR YOUR RECORDS v? -1 '0 p o a y cQ O o m � � m n�i �, s � n�i � O � uf � � ci � 3 � �� _ cu � c: � � � �. � 'n � (Q N �Q � � 3 � y � t�n � � e'7 �D m � � O j � � � � Q � Q � _ � -C�I �, p .� p � C� �� G � � � Z = -< 3 -, o � ° � 3 D = -� 0 v o � o� m -, < Q D O � D � O a � o� O o- ?:�- p c c� � — � { � m a ntDi s� �: � � D � cnD -+ < cD a. -, G� I�' Q � � � � Om � � = m cQ � � � a � � v"�i Z � m ? �.'� � � m ^' � o . co _... c� v � ° 0 � I � c�n ,� ci m � � � � c o O � � � � � Q � � � r. � n� c co a� r" -� � °. � � � � � m O � 3 rr D �" � o- � oci � Z n � � � m ua pp ,� Z � _ m � a. � W O Q �. � �° � ` W ao '- m o � m � o co � �� a. � tQ tn �a �' s g � n D - � � m Z � � �• N � D Z o � c n�i a v� -i rn � m � a� 2 � x 3 ° � V � m � � � � � � � � o � O� .� � ? .. � v � co � m ,u�, cQ � � � � � � � .. � (�D � � < � cfl cs� v� t� rfl � �j � � � � t71 0 o N < � �O W O rn 0 � � � p O �D n (D � � O � � --I � C� N T � O � �_ � o � ° '�,..,�-