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Youngquist RECEIVED MAR 0 4 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��sot�LERK Mi�anesota State Stntute 466.05 states that"...every��erson...who claims darnnges,frorn any rnunicipnlity...shall cnuse to be presented�o the goveniing bod}�of die»T�unicipalih�w�ithiri 180 da��s after the alleged loss or injury is discovered a notice stating tlae time,place,and circumstances thereof,and t%te an2oi�nt orcompensation or odier relief demantled." 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 PAUL, MN 55102 First Name,,��5(�{, Middle Initial�Last Name t'�Gy L�.-V1�'�'-'1��(_i S� � Cornpany or Business Name -'- Are You an Insurance Company? Yes/�If Yes,Claim Number? �..� Street Address ��<'r�,�a ( �� ,(��J� f'�'1i�-C'�L-1(-� City�� • ��z.,t l_ 1 State �j,,{r�) Zip Code� Daytime Phone( ) - Cell Phone(��"b��ing Telephone( ) - Date of Accidend Injury or Date Discovered ' Time�am/� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why ar how you feel the City of Saint Paul or its employees are involved and/or resp nsible for your damages. I �� t , u � � � �� l��-%�C 4��iN.�--�'��-��-�✓�2� ��.�h r,� �'� �-b�i"� �� — t a ,L�2'.i'lb S�e.l-e�_a''--F�- �''��1� C'l�� L�� , `'9 -c�' 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 rype of property damage-please specify ('� rir-�'.--�, -�-1 �-e� jv� -�-�_�'t-' '� c�Gt--� '�z� ❑ Other type of injury-please specify �?�� 1.ZG�a vi �O�R-�.�- . 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 ar 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 �Other property damage claims: two repair estimates if the damage exceeds$500.00;ar the actual bills and/ar 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–please comnlete this section Were there wimesses to the incident? es No Unknown (circle) Provide their names,addresses and telephone numbers: �___r___�, ' � '' �' � � qg� C t`�Q'�b` i�,`��s�t�%t'1�4�In �-�-�t-� S�, Pd-Z.,e�! , �(,(..,U ��I l 6 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 or facility, closest landmark,etc. Please be as detailed as possible. 1f necessary, attach a diagram. I,'l.°,�t�.�,��,z_�e.r� �-�� - ii '� .(�.i�.-�n `�' !�1 i_��R-t'�.��' �,�� Please indicate the amount you are seekin�n compensation or what you would like the City to do to resolve this claim to your satisfaction. � . � •, Vehicle Claims–please complete this section �check box if this section does not apvlv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injurv Claims–qlease complete 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 When did you miss wark? (provide date(s)) Name of your Employer: _____________.�_ �_—_-- - Address Telephone �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 �� Print the Name of the Person who Completed this Form:��j � V1 r� 1 G��,L l�"� r Signature of Person Making the Claim: � � Revised February 20l I City Clerk 15 West Kellogg Boulevard, 310 City Hall Saint Paul, MN 55102 March 2�d, 2014 To Whom It May Concern, My name is Alyssa Youngquist, and ! am a home owner at 1786 Wordsworth Avenue. My home was affected by the water main break on 7`h Street W & Davern on January 29`h. Soon after this date,the toilet in my basement stopped working. It had no water in the tank and would not flush. According to Ken's Sewer Drain & Plumbing Co. (http://kensewer.com/),the cause was the water main break that had backed up in my toilet, causing sediment to create a blockage. I was able to get this toilet fixed on February 10`h at a cost of$130.00. I would like to submit this$130.00 bifl to the City of St. Paul for reimbursement. I have enclosed a "Claim Form" from the City of St. Paul, and a copy of the bill from Ken's Sewer Service Co. I appreciate your attention to this matter. Thank you! �� ' Alyssa Youngquist alyssajyoungquist@gmail.com 651.343.4653 1786 Wordsworth Avenue Saint Pau►, MN 55116 —_-— -- -- --___ —_ -- —_____ _ �� ;��„ 't��°�'E� ��lf�4E ��. a�'st� �.4ea�:€a� • �`su��-i,�g ��'s� 3�i>c:ate3�ez Ave.S. 19ih^.Grasra�ne. "n?l:..^:Eapolis�a°�?;'s 55$10 St.Paa:i,PhPd 5:iiia:t _ _ _ _ — p %4s�}9i3-�I46 �f&a!}e�3`�-�a3� II :,3iG)��'�L31^L c��D v�JE�-7l`+s°J� � . —j E ;93�f 9�-�55� f:2�3)354-.��33 � �; SOLD BY i � DAT � �, ' p �y E ��•� � � _ � �j ' � Peel off& place on furnace or water heater NAME(� _ �; -,, KEN'S SEWER SERVICE C0. ; : �'�� ' �.�.� _' �� '--'� � ° ; � We Clean All Types of Drains i � k 3DDRE�SS �� `� ��C �. � ,� �� Plumbing Repairs • Frozen Lines • Camera :, � : �,� ; ��,p . c,-,�ae or�:�ccr 952-929-4146 651-698-7639 612-722-2212 ` � 763-545-2339 612-722-1990 651-698-6547 � ` � � % '� ' � / ♦_ c, �, ....................6...4..Vj'.�..,fi:........._......._.._....._.........,...................................¢.i��-.t.........._.... � � f f !`� � � ' •i � - � � . i % � / � f � p _i.t_c�..s.�.E_L�:.Y..,_�...._..__...._....._._....................._.........'.....:-.............. . i. s %� , , , :, {: ��v , y y �{� �� i . = ....................................`:.......�.�.T-.._................................................................ ..... I � �+-` � � r € ._.. ._.._....... .........._..... _...... ".��... . ...... ............. ......... , L i. ...................................__..........._..._................................_......_.................._.................._............. � i- z . ................................:................................................................................................. 4.. _........._... .. �- �- .._.__............................._......_._..........._.........._........................................._....................._.....__... �J;:z O�Rec��t��?"nis I:�•r;:�e. � ��.:Ai�c-��s�i-�-baSfte�arr�fi�r _ _..__... +"�ry•A�FGcab[e E'Vzera�A.re FraRatetf iy E�.� RECEIVED BV � � � t � AII claims and retumed goods MUST be accompanied bythis bill. R � T�Reord!r �� E 3 '! ?0� eoo-��sa o��.�m `Yo�r F i