Rodriguez Montoya RECEIVED
FEB 14 2�14 RECEIVED
NOTIC� OF CLAIM r�RM to the C¢�J�'q�f�ii��ul, Minfi�o�� 2��4
Mirritesota State Stutute 466.05 smtes dznt "...every person...whn clni�ns dumn�e.s./'rom nny municiperlity...shall cnus�k�p�es��i �
go��erning budy uf d�e municrpnlity��idri�i 180 duys after tlie nlleged loss or i�yi�rv is discovered n notice stnti�tg tlre lime,plcrce,and
crrcwnstnnces tl7ereoj;nnd d�e aaiount of compensalion or other relief demnndecl."
Please complete this form in its entirety by clearly typin�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 clarif'y answers,so provide as
much information as necessary to explain your claim,and the amount of compensation bein�requested. You will receive a
written acknowled�ement once your form is received. The process can t�ke up to ten weeks or longer dependin�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
First Name �,��('C1�� Middle Initial Last Name �d�. �� 11 � C � C�
Company or Business Name
r
Are You an Insurance Company?�� /� If Yes, Claim Number?
'�„'
Street Address 2--cJ� � C '� ��l c�
City �1(7�f?�P 11.�r('�� State �� Zip Code�U�
,- q �
Daytime Phone ( ) - Cell Phone (�}3��-"103�Evening Telephone( ) -
Date of Accident/lnjury or Date Discovered�� '�� "! Time am pm
P1e�!se st�t�, in detail_, what occurred(happened), and why you are submitting�i claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
Please check the box(es) that most closely represent the reason 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 � ��-�'-�'�(%�� ���� '�`��,� v ����'
• ❑ Other type of injury—please specify
ln 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 WILL 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 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
Failure to complete and return both pa�es will result in delay in the handling of your claim.
_ All Claims-please c�plete_tli�section-.' _ -- j\ — -- --- -----___
Were there witnesses to the incident? Yes � 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? `� k �Ltu� ` G�. Case#or report# �� Z�L,36 ��
Where did the accident or injury take place? Provide street address,cross street,intersection, name of park or facility,
c t landmark, etc. Please be as detailed as possible. If necessary, attach a diagram.
�c��,u � �, S'� °� t+�`�
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.
Vehicle Claims- lease com lete this section ❑ chec � box if this , ction does not a I
Your Vehicle: Year �� �^ Make�t,� ��Model � '> �►�p
License Plate Number�y'[�_ State�l�Color OIC�
Registered Owner��?.�(ci_�_`� �-c�c�i� cpvt..,Z 1-'�G�'1�z:,�lQ
- - Drive��f Vehicle �
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
In jury Claims-please complete this section �eck box if this lection doe5 not ap�ly
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
When did you miss work� (provide date(s))
Name of your Employer:
Address __ _ ___ Telephone
❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages
By signing this form,yoac are stating tliat ull information you have provided is true and correct to tlae best
of your knowledge. Unsigned forms will not be processed.
Scebmittiitg a false claim can result in prosecution. Date f'orm was completed
Print the Name of the Person who Completed this Form:
Signature of Person Making the Ciaim:
Revised Febru�uy 201 I