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ll4innesota State Statute 466.0.5 /��OTICE Of CLAIII�'. .%E)very pe�son.., who clain�s damages from 2ny �
m,unicipaiity.,.shall cause to be presented to the goveming body of the municipality �vithin 180 days after the
alleged loss or injury rs discove�ed a notrce stating thA time, p/ace, and ci�cumstances thereof, and the amount af
compensation or other relief demanded.
Please complete tl�is for►�� ICl If5 entirety by typing or printing your ans���er to each q�testEOn in
the s�ace provided. If additional space is needed, please attach additionai sheets.
� _
�� ' PLERSE RETURN THIS Office of City Clerk
COMPLETED FORM T0: 170 City Hall RECEIVED
15 1N i<ellogg Blvd �aN p
St Paui MN 55102 3 2�14
Your Name: _��J�� _ �0 �ITY CLERK
Street Address: �lQp �Q�_� �l - -�t�l _
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City: M� �Q Ll'�f_��—_—_.— State: t"� Iv Zip Code: (yl��
Daytime Telephone: (�S�) �J3 '— ��� Evening Telephone: ( 1 �"f�t�(�,f
Date of Accident or Incident: Qj1��Day of '✓Veelc: Time; � am or pm (circle onel ,
Please state, in detail, wl�at occurred and tl�e circumstances surrounding the event. Indicate how the
City of Saini Paul is involved, and v��hy you feel the City is responsibfe.�
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Please indicate your reason for completing ��;i� forrn:
f.-�-1 Vefiicle accident 1:=1 Other property damage (please provide specifics below) ' i�
❑ Vehicle was towed � �,I
'i
Vehicle damaged ❑ Other in ur � to erson ( lease rovide s Pcifics hea��ti�) �i
� ) 1 P P P P- . .' �;
� Slipped and fell on City property '''`
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Please provide the names and telephone numbers of any City employees involved in this
incident/accident and I�ow tl�ey were involved:
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fcver)
!i your vehicle v��as involvec� please complete the follo�n�ing:
';'�ar, mai�e, and model: License, Plate I'Jumber: ���-- C..Q�
Extent and area damaged: � +p�
\Nas a City vehicle involved in tl�is accident/incident? es No (circle one)
ir yes, please complete tl�e foilowing: Type of vehicle
Year, mal<e, and model
Color of vehicle License Plate Number: -
DescriE�tion of vef�icle
Location of accident/incident (please ��rovide specifics sucf� as st:reet address, intersection, cross streets,
� park name, facility name, etc.):
Please draw or attach a cliagram if a�plicable:
_ . _ _
�
Please specify the nature and e>;tent of the compensation or other relief you are requesting. Please
attach copies of any bills, receipts, ticl<ets, or other documents �o support your claim. If you are
claiming damage to a vehicle, please submit itivo estimates.
v�ere iiiere ��vitnesses to ti�is accidentiincident! Yes No (circTe one — - - - -
i '
If ��es, please give the names, addresses, and telephone numbers of the vvitnesses:
\Nere the police called? Yes No (circle one) If yes, what department or agency? •
Police report number: :
Please print the name of the � �
person completing this form: _ � (�
Pfea�e sic�n your naR�e: ��
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D2te �orm signed: Q`_T I �
Risl: Mgmt Division - Revised 1 -30-01 j,�;l�li,�
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