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yang, Lee ��cEiv�D NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota��B 13 2���+ Minnc�so�u Stute Suuute d66.0?.srares rhur"...ei�er�persun...�rhu,•luDrrs drtmuge.s.frnm uirr m�uticr/�ulin...shul!cu�ece ir�Ge��rc e e h Lorernin,�h��cl� o/'the nuaiici��u(ih �rid�in 1 RO drn.s ufter the ui(c•,L'ed In.r.s or nij�u�•r.s discerr<�red u nntice.stulirr,��lre tinre�.��lucc'��� �LER� crrcumstu�ices th��renf,und the cunnunt nf cnnrpen.intrnn nr nther relie�t�c(enufniled... Please complete this form in its entiret�b�•clearl��t��ping or printing��our ansK•er to each question. If more space is needed,attach additional sheets. Please note that��ou«�ill not be contacted b��telephone to clarif��ans«�ers,so provide as much information as necessar��to explain�our claim,and the amount of compensation being requested. You���ill receive a �;�ritten acl:no�rledgement once�•our form is recei�-ed. The process can take up to ten«•eeks or longer depending on the nature of��our daim. This form must be signed,and bcsth pages completed. If something does not apply,�rrite`N/A'. SEND COMPLETED FORM AND O'CHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name ��H� Middle Initial Last Name G��1 Company or Business Name ��E � f,�F�"� �� ¢ �5�, �Gcv� Are You an lnsurance Company'? Yes No If Yes,Claim Number° Street Address •1'i��°y �C� `'s�/'a'1 " � City � �.�n`� �ii� State /l1�'✓ Zip Code �5%I`7 Daytime Phone ( ) - Cell Phane(�L)�- "13 bG Evenin=Telephone ( ) - Date of Accident/lnjury or Date Discovered :113��/��y' Time � 0 <m/pm Please state,in detail,what occurred(happened),and�hy you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involved ancUor respontiible for your damages. Oti ��n.r,�d+r� . � � TpM�R�'pst-�j � a vf' .`z�� A� r`r r+-�b ti�iC -� u�. � b.2 r7 yS/�tlfiu' �Ui�/ /rJ J 7�2 t?, �- ,�i� � � G;�� .v rV 'y3{ic J o.v � /e�f' ..� 0 �e e t-c. /�'►^^ J-� J��. Q fil' � L' /�-i�+-� a- p , � Please check the box(es)that most closely represent the reason for completing this forrn: ❑ My vehicle was damaged in an accident ❑ My vehicle ��as dam<<ged during a tow ❑ My vehicle was damaged by a pothole or condition of the street �My vehicle was dama=ed by a plow ❑ My vehicle was wrongfully rowed and/or ticketed ❑ 1 was injured on City property ❑ Other type of property damage—please specify_ � Other type of injury�—please specify In order to process your claim vou need to include copies of all aaplicable documents. For the claims types listed below,please be sure to include the clocuments indicated or it ti•ill delay the handling of your claim. Documents W1LL NOT be returned and berome the property of the City. You are encouraged to keep a copy for yourself before submittin=your claim form. O Property damage claims to a vehicle: two estimates f��r the repairs to your vehicle if the damage exceeds �50p.(}0;or the actual bilis and/or rereipts for the repairs C►4 rv"�c7' !>>'. r v�z- -�j .s'i/u p O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other propeRy dama�e claims: tti•o repair estimates if the damage exceeds�500.00;or the actual bills and/or receipts for the repairs;detailed li�t of damaged items O lnjury claims: medical bills,receipts ''�Photographs are alw�a�s welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pa�es of Claim Form �+ . .... .. .d-� . . �_, .. . .. . ,. ,. - _ - -_ = a . t L : • � _ " � ` •:�"� . . . � i-'.R x$t'!�.. :h i �:� .,� �.?'` .. - �i .?w�` �� -. - ! � . . . S _ I , -. � .. . ' . � .., t".. .� . . . ... . � . � . . . ' .:'i. . , - . � ; . . -� , . .. . . . . .�.'. . . �:}F r .� . . ...� . ... . - �.. .. ._ f: ` _" r . .'.�:.µ- ..� . .... " i ,, . �4'e' .. 1 . �. .i� , � , �c. , ,, ., .i . ;s' . . . !t . �, �;r.l;� ... :E�'r . . Y . sJ ,, . , � r .r=' :i., .r}:a�E.'r . . . .:`r' , . . . , ,. i ta . Fa�-, , 4� .: , s � .� � .� , . � r�..d�. k r r`.,az � `�w� . , �•';? {a a1�.t � �?,`.3 # i i'ii v�.:# j ��,;:,.�`_ . - -Y�fF � { � . -�, !. , � :� , &3 t ; .$ ,�.�S ' t� . .. ., . . , ... � . . .. . , . _ P�i . . -'s . . _ . e. . i.. , � : .. � . . . . . �._.. .. .� . , , .. - , . . . . � � . . .. . , _ , _. i, Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease comalete this section - W'ere there��itnetises to the incident? �Y�i' No Unknown (circle Provide heir names,addresses and telephone numbers:_ V��IC �Cr d�1'*i1 rJ;�6or�it�e �orr J(f��� �,r' ��.t�NSS�/7 �6S/7 3�1�c��5 Were the police or law enforcement called'? �es % No Unknown (circle) If yes, what department or agency'? ���'�p��/ � /� Lc� Case#or report# 11/` O/q 0�8 L Where did the accident or injury take place'? Provide street address,cross street. intersection, name of park or facility, closest landm�u-k.etc. Please be as detailed as possible. lf►iecessary.attach a diagram. it� � �f �►�� �Cs� .� s7-. 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. /�/G� T_ /.�- ✓�L � T7� b �'-•�- L-S' ��rn�1 TL-� . U` j c�c��,.`j f,� Vehicle Claims- lease com lete this section ' � check box if this section does not a 1 � Your Vehicle: Year vo.� Make A-_Moclel � ��� C= License Plate Number D�''�/ T'l� T State /'i'►/`�Color I aL/C Registerec!Owner L+�z i/A�v�%i Driver of Vehicle � ��J ��l�= t� U.'V � lXe�'� Area Dama=ed F'►'�:� q- �f�u�v T- City Vehicle: Year Make Model � License Plate Number State Color � Driver of Vehicle(City Employee's Name) Area Dama�ed Iniurv Claims-please complete this section �check box if this section does not at�ph� Ho�v ���ere you i.�jured•' What part(s)of your b were injured° Ha��e vou sou�ht medical treatment: Yes o Planning to Seek Treatment(circle) When did vou recei��e treatment'' (provide date(s)) Name of Medical Providerls): p��rztis Telephone Did you miss work as a . t of your injury'? Yes No When did you mi ork'? (provide date(s)) Name oti mplo}�er: Add .s Telephone '�'Check here if you are attaching more pages to this claim form. Number of additional pages �. P��s By signing this form,you are stating that all informatio�r you l:ave provided is true ai:d correct to tl:e best of your knowledge. Unsigi:ed forms will not be proeessed. Submitting a false claim can resu[t in prosecution. Date form was completed ������l����� Print the Name of the Person who Completed this Form: �t��, YM ^�N1 Signature of Person 1��Iaking the Claim: 4 � � °�� Revised Februarv 201 I � „ . . .m � ti; �z �xa � .. �.�, ;..,.r ,�, � :.;�.�>�: �r�a#_�: , .-�iY��-�sk'i� �1�6 S��'; a�i � ,. :i4�,;��. +ci�'e���iV: : .�.,... �«-., .... ,.,(. . ��F»�.°.� �:,, -t �...ti.`'..1> ^x. . . i n ... � . ... � . ,a . 3 .. � 'l Q°: .' , - , . � .... ; .�.:.. �. . . �, ...�..� j . �� . . _ � .... ' `�A,•' _ . . . .�rF'-�.. .:i��,.. 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