Yang, Yiz RECEIVED
MAR 0 5 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Min���Y CLERK
Minnesota State Statute 466.05 states that "...every person...who claims damages 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 siating the time,place,and
circumstances thereof,and the amount of compensatian 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 PAUL, NIN 55102
First Name `�j.� Middle Initial Last Name �7n�,t?
Company or Business Name
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address I� 2Z �c�•1 kS �1 vG
City S�i NT pa�� State MI� Zip Code ��0
Daytime Phone (�)5Z$-$�al Cell Phone(_) - Evening Telephone(b�51 )�- $��
Date of Accidend Injury or Date Discovered +�1�2 a r� Time �=O0 am�
Please state,in detail,what occurred(happened),and why you are submittiug a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. �:a1� �►f a S
?vw�j A-Ftcr rs.ltasihc �4.� ��. R�sr o�' �r '�'j'Dfl.�s .
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 copies of all apalicable 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 W ILL 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
• Towing claims: legible copies of any ricket 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
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
�s
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 wimesses to the incident? Yes 1� Unknown (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 or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. 11�-2 � rw��C�
;�r•tb �2z►�lk �KsT ou. si Ot o-F e^•J •�Sc
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your sarisfaction. Ps� �+'r t'c o a�c- i�c �'c D�t(' t� h�d t�• --
Vehicle Claims please comulete this section ❑check box if this section does not app�
Your Vehicle: Yeaz 200� Make To�(oTs Model��� L a�.l.'DeF�
License Plate Number SSS 4 B'� State t��1 Color I'1��oo�
Registered Owner `� � `�zp{,�i
Driver of Vehicle `l�� �z��j.
AreaDam ged ?Ztmf�t. o� Ti�c �e.l�'c �L –
City Vehicle: Year 14 Make Model
License P ate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In' Ciaims– lease com lete this section ❑check box if this section dces not a 1
Nnw wPrP vc►u iniured�
__�.. ..-- � -- --.. —
What part(s)of your body were injured?
Have you sought medical treatment? Yes Planning to Seek Treatment(circle)
When did you receive treatment? ��� (provide date(s))
Name of Medical Pr vider(s): /A
Address � Telephone
Did you miss work as a result of your injury? Yes �
When did you miss work? R (provide date(s))
Name of your E��loyer:
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 e_3�d 3T a��
Print the Name of the Person who Completed this Form:_��-9� V��,g
Signature of Person Making the Claim: � C�
Revised February 2011