Pak RECEl�lED
F�B 2 8 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, Min��aCLEF�K
Minnesota State Statute 466.05 states that"...every person...who claims da»mges from any municipality...shall cause to be presented to the
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 typ�ng or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you wi11 not be contacted by telephone to clarify answers,so provide as
much inforcnation as necessary to ea�plain 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 PAUL, MN 55102
First Name �`�r Ii�l Middle Initial L Last Name P��
Company or Business Name �
Are You an Insurance Company? Yes!� If Yes,Claim Number?
Street Address '��'�o �I t't M l i�1e t1v� S. # �
City Sfi ��u� State M N Zip Code �����O
Daytime Phone( ) - Celt Phone(7�'� )�'��-1��� Evening Telephone(_) -
Date of Accidend Injury or Date Discovered Z� �`� � i� Time /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 and/or responsible for your dam�� ages.
I h�cd �rrev� W''�✓�tl,t.�,y �1'()W"ec�. 1 liV`e GLL'rCSS }V�e JtrC�f v��d l�ucl j'i�✓t:�cd +h�r� thc�,d h)r�ht
c�lFfzr r6�e �tVeei kad �� �tpW�d TI� St►'��f wltS Gl�itiv� iai�d �fte��tr�vit� �� wi��l�e aovw,
tV�ctfi vbG,d thC+��e w^er�� �1a �iow tv�n.t,l�s Vtti��. � ►Vhv►�ec�i�tfz1y C�rflcr� fl�e +v►�Po���d t�3 4'v'��1
(AS �1cl�t-hv�r� C�v�a� �h7w S�Yv1CCf -fvr htt� wit�^ tlne S�tulafilv�l �tV�titvVt��V�i�� v
ti�v�ry Unc� he�cci c��A l�t�c�� c ��i�;ilJ �,s��crh� lo�ii-hE�� : �S i -ZU� -�1�vy
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
❑ Other type of injury—please specify
In order to process your claim vou need to include conies of all apulicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay[he 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
( $�,00.00;or the actual bills and/or receipts for the repairs
�f��'1'owing claims: legible copies of any ticket issued and a copy of the impound lot receipt
� 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 pages will result in delay in the handling of your claim.
All Claims—ulease complete this section
Were there witnesses to the incident? Yes No �l�'�"d�'n (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes � 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 ar facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.(NiIN 1i►1�� Ki1nd D If�
�j r� �-vU-` f 't�n i�vtcK �s i�s �,-rien - tic�vtr u✓� i�V►uwi �,xc��t loCl1-Ficv� �,s1-2�4 - ��b�y
S veet
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. �2�� �uV fiol/�:�VtEI� / l rVl{'ci�t Vi cI L�i Y i"e V�Gv�+-t'
Vehicle Claims—please complete this secdon , ❑ check box if this section does not avplv
Your Vehicle: Year Z���5 Make F u��� Model �����;
License Plate Number `�blt EK�^ State ►�N Color glae�
Registered Owner �i�+r�,+k Pcr,i�
Driver of Vehicle Siavr��i Yw1�
Area Damaged X
City Vehicle: Year Make Model
License Plate Number State Colar
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section �J 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
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�] Check here if you are attaching more pages tb this claim form. Number of additional pages � .
By signing this form,you are stating that all information you have provided is true and eorreet to the best
of your knowledge. Unsigned forms widl not be processed.
Subinitling a false claim can result in prosecution. Date form was completed 2"�20 � �`�
Print the Name of the Person who Completed this Fortn: ���'�� ��k
Signature of Person Making the Claim: C r �
.
Revised February 2011
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