Lee, Lolita RECEIVEQ I
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota201� �
CITY CLFf�� �
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municip¢lity...shall cause to be presente to t"e' �
governing body of the municipality within 180 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 additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending 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 PAiTL, MN 55102
First Name��(.f�`�. Middle Initial �� Last Name d�
Company or Business Name
- ------ -- - - - �
- __-__ _ _ - -- -- -- -
Are You an Insurance Company? Yes/�Yes,Claim Number?
Street Address �.r� �f' �
City GzL� State /`-�� Zip Code �D
Daytime Phone(�)'7���" ('ell Phone(��) �J� y'�vening Telephone�� -
Date of Accident/Injury or Date Discovered O//�-J�/ � Time ��•��3 a /pm
Please state,in detail, what occurred(happened), and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved andlor responsible for your damages.
,.Z� � �C' d <�,� 1/�Pd'��-L. � .f> �ar�S S �� ;S'
`�J �- �-h ..-�Le
8�t, /� � ��l l' �"�'
Lv,`�I h-L �a.% i'�.,�.. — �s a�.e - tv�an /Lt r9-re.,
�- c�l f�'lu "�e �oas � .S�' K- na- r�=a-
!: � c,l t . sS` /�'1c a ��e l�r. .�`�
/.° .0 I.f W
Please ch�ck�th box�s)that most closely er presen�e rea�son 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 _
_ n *,r ...--��: �'.,..�,�—u:'.Y-'-ic.:.:,��'°i"`'.i — — — �I w—a�T'�.ucu i �,i y v�.ici�y_ _
-- ..r �,_�' »., .. y �.. v� .,.,n.,�.,..
❑ Other type of property damage-please specify
❑ Other type of injury-please specify
In 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 WII..L 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
andJor 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 retumed.
Page 1 of 2-Please complete and return both pages of Claim Form
i ,
,
s:
Failure to complete and return both pages will result in delay in the handling of your claim.
AlY CIaims-nlease complete this section
Were there witnesses to the incident? Yes ��No Unlrnown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what departrnent or agency? b ` r Case#or report#_��� ,�`
Where did the accident or injury take place? Provide street address, cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If ne'�ces�, a`c�a diagr
/J''�d�X�/��,-��ue 41 �i� � � ^--t
i�� Please indicate the amount u are seeki�in co ens tion or what you would like e City to�to resolve this claim
to your satisfaction. �. .
- � v ehicl�C�aims-- �ease com lete this sectio ❑ check box if this section does not a 1 �
Your Vehicle: Year � � ake �L Model
License Plate Number � State � r� Colar
Registered Owner � -�, �{ �
Driver of Vehicle ' "
Area Damaged
City Vehicle: Year tJ Make Model
License Plate Number State�Il�Color �(
Driver of Vehicle(City Employe s Na e
Area Dama.ged
In'u Claims- lease com lete th' section ❑ check box if this section does not a 1
How were you injured? p� ' S--
. �
1' '
What part(s)of y ur body w re inj ed?
_,_- —
Have�you sought medical treatment? Yes N ` lanning to Seek Trea t(circle)
When did you receive treatment? ( f�_-... (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your i �ury? Yes No
When did you miss work? 1 (provide da.te(s))
Name of your Employer: - - -
Address /j,o Telephone �S1' a�/ -6�2D
�Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all 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. Date form was completed d/ 31 f
Print the Name of the Person who Completed this Form: �h�-u y����
�
Signature of Person Making the Claim:
Revised February 2011
� j`
e' - Page 1 of 1 {
� - -
�;
� k�
� ENTERPRISE LEASING COMPANY, 395 EAST 7TH STREET, SAINT PAUL, MN 551012450 (651) 225-9766 �, �'
� RENTAL AGREEMENT REF# SUMMARY OF CHARGES
:��9895 6TUZOG
Charge Description Date Quantity Per Rate Total
RENTER TIME & DISTANCE O1/30 - 02/13 2 WEEK $179.99 $359.98
-�-- -�'-`,�' DW O1/30 - 02/06 7 DAY $15.60 $109.20
PAI O1/30 - 02/06 7 DAY $3.39 $23.73
DATE & TIME OUT REFUELING CHARGE O1/30 - 02/13 $0.00
"�'� '3��;2����.a 03:25 PM ?::
DATE & TIME IN Subtotal: $492.91 i, I�
S2i13�2014 01:35 PM Taxes & Surcharges ;i '��
MINNESOTA REGISTRATION ?`' k
BILLING CYCLE FEE O1/30 - 02/13 5% $18.00 ,i,.',,
� u MINNESOTA RENTALCAR ,i;
� � v� TAX O1/30 - 02/13 9.2% $33.12
" VEH #1 2013 HYUN ELAN 1GLS SALES TAX O1/30 - 02/13 7.625% $27.45 ;;
..,_ �r,PGh4AEXDH388598 Total Charges: $571.48
_,C= sb�GAS
�
i-1ILE5 CRiVEN 344 Total Amount Due _ $Q.�O —
�
CLAIM INFO PAYMENT INFORMATION
�WG�. „�R.4 f�1APLEWOOD*' pMOUNT PAID TYPE CREDIT CARD NUMBER
i,TTP,. „�P�KfvGvVN �571.48 Mastercard xxxxxxxxxxxx9978 PENDING
�
{ ;,
� • a
;,;
n+
p+,
i'I.
ii
n.t
p'�
,'.,�
� , . . . . .`�,,.
5)
f4'
i �'
�
ie
t"k
4 '�i+
�
��'
��,
' _ � - �'il]-� �,
� �
ABRA-5215 Maplewood
?806 Highway 61
Maplewood, MN 55109
(651 ) 483-?1�5
FEB 13, ?014 10:33 AM
REFERENCE 14043-103?
MC XXXX9978
TRANSACTION: 541910?73
AUTHORIZATION: 89475Z - --
AMOUNT: $100.00
LOLITA S LEE
I AGREE TO PAY THE ABOVE AMOUNT
ACCORDING TO THE CARD ISSUER
AGREEMENT (MERCHANT AGREEMENT
IF CREDIT VOUCHER)
- Thank you -