Thao, Mai Vue - � � � RECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota���
CITY CL� �
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...sha[l cause to be presen e o h
governing body of the municipa/ity within/80 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additionai sheets. Please note that you may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. 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 /�'i 1� Middle Initial Last Name ��.�
Company or Business Name, if applicable
Street Address f 3� �/ �/P�� 'rn s�er-s � � .A�"-�_—�' ���2
City �'� /�'�cA�� State Y v ! v� Zip Code � 3�
Daytime Telephone( SI ) -�,�- ��g j Evening Telephone()
Date of Accident/ Injury or Date Discovered �Z-����'�3 Time am/pm (circle)
r
Please state, in detail,what occurred, 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.
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Please check the box(es) that most closely represent the reason for co�leting this form:
� Vehicle was damaged in an accident ffd Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
❑ Other type of property damage-please specify
O Other type of injury-please specify
❑ Other type not listed-please specify
In order to process your clai�n you need to include coaies of all applicable documents. This is a general
guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates, detailed list of damaged items '
O Injury claims: medical bills, receipts
O Photographs can be provided but will not be returned. �-
Page 1 of 2-Please complete and return both pages of Claim Form .
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul, page two
All Claims-alease comalete this section
Were there witnesses to the incident? Yes �� Unknown (circle)
If yes, please provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes o Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park
or facility, closes�landmark, etc.-Please�e �s detaiied as possible. Ifhelpful, attach a diagram.
_�._ i'tiTt''�'13YC. ��.�...� �?LL���a�� . t�a� crw�-��l�zee �
t�n� �-a��
Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction.�'� x ,�� �,�� na_..5�� S;z.��e c�-{
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Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year_� o0 3 Make Model G�I-e-e.
License Plate Number �C�Gl�'�/� State�Color dGV-6c �f,��,�,�
Registered Owner
Driver of Vehicle
Area Damaged - ;e
---- --Gi_t�-.�-e.hi�le:__Year - Make _Mc�del
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-nlease comnlete this section ❑ check box if this section does not applv
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
_ _�Nhenllid 3cou mis���k? —— - (provide date(s))
Atame of your Employer: � ` � - -
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this jorm,you are stating that al[information you have provided is true and correct to the best of your knowledge. Unsigned
forms will not be processed. Submitting a false claim can result in prosecution.
Print the Name of the Person who Completed this Form: "]�.�j 3 �n ��Gt 1.�r,�
Signature of Person Making the Claim:
Date form was completed 'Y-``Z-6 /` /y Revised April 2007
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FLATBED S.WHEEL LIFf TOWING OFFice 651-247-9783
JUMPSTARTS,LocKOUrs& Fnx 651-641-1818
PRIVATE PROPERTY IMPOUNOS PLCRECOVERY@YAHOO.CDM
PO Box 4025�ST.PAUL,MN b5104