Ristow � �E�s����c�€���c ��a� F����� ���Q�i�� ��� ��a���� �a ���y o�� ��E�� �a€�� � � :
ll4innesota State Statute 466.05 NOT/CE OF CLAIM...(E)ve�y person..�who c/aims damages from any
municipality..,shall cause to be presented to the govern;ng body of the municipality within 180 days arter rhe
alleged loss or iniury is discovered a notice stating the time, p/ace, and circumstances thereof, and the amvunt or'
compensation or other�elief demanded.
Fiease complete tl�is for��� in its entirety by typing or printing your answer to each question in
the space provided. !f additional space is needed, please attach additional sheets.
� RECEIVED
- �'-' PLEASE RETURN "fHIS Office af City Clerk
COMPLETED FORf'JI T0: 17� City r-iail � � �� ?��� -
15 W ICellogg Blvd CITY CLERK
St Paul MN 55102 ,
Your Name: C��� � �D
- Street-AdcJiess: -._ _� __ _ _ -�.� r�.__ .. _ _ . .--- __ -__. . -- -- _------ - -- ....__. _ ._ - _ __ _ ----_ --- ..
City: �ry���s�� _ State: � Zip Code: ,J�i� Z>
Daytime Telephone: (��'F ) �7-yL� �-- =vening Telephone: �_�_ __
� � �
Date of Accident or Incident: �� �Day of Weel<: �, Time; d am or� (circle one) ,
,
Please state, in detail, wi�at occui red and the circ��m�*ances �urruu��dir�g the ev�nt:-"inc�icate how tFie �
City o�int Paul is involved, and why you feel e Cit is responsible.
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Please indicate your reason for completing this form:
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C.:1 Veliicle accident f.-7 Other property damage (please provide sper.ifics below) ;;.;�I:
/� Vehicle was towed _ _ '''
":;.�:
-- � Vef�icle damaged D Other injury to person (please provide specifics below) `��'
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❑ Slipped and fell on City property - �'i '
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Please provide tl�e names and telephone numbers of ar�y City employees involved in this r ;
incident/accideQnt �nd t�ow tl�y were involved: � ` A
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If your vehicle ���as involved, please compiete ihe foll �n�in : � ,.._,
Year, mal:e, and m�oo'el: � J 6, d��o'�'� ����) License Plate fVumber: (�R( �
Exteni and area damaged. o/}� �_���
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Was a City vehicle involved in this accident/incident? 1'es ��circle one)
� I.f yes, please compiete the following, Type of vehicle
- Year, mal<e, and model
Color of vehicle License Plate Number: -
Descri��tion of vef�icle
Location of accident/�ncident (please �3rovide specifics suci� as street a�.dress, intersection: cross streets,
park name, f�r.,,iLty name; etc.): /
�7't� �� � �
_ .._P_lease_draw_.or attach_a_cliagr_am.i_f_a�plicable:
_ _ _ _---. ___. -._. ..-- -- - --
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Please specify the nature and extent of tl�e compensation or other relief you are requesting. Please
attach copies of any bills, receipts, ticicets, or other documents to support your claim. If you are
claiming damage to a vel�icle, ptease submit two estimates,
W��1 �"� ��_csd,._ � 1/1/a r
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Were there witnesses to this accident/incident? Yes No (circle one) -
If yes, please give the names, addresses, and telephone numbers of the witnesses:
�
�Nere the police called? Yes No (circle one) If yes, what department or agency? a �
Police report number: -
Please print the name of the
person cornpleting this form: �..'�'� ��5�'d �
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Please sign your name: � ��''7 � i,�
Date form sigred: I
I;:,
Risl< Mgmt Division - Revised 1-30-01 �"f;�,i(�:
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