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F L FORM to the Ci of Saint Paul Minners�o��-C�ER
NOTICE O C A�M ty , K
Minnesota State Staurte 466.05 states thal "_..every person...wiu�claims damages fran arty municipaliry...shall cause ta be presented to the
governing body of tfre municipntiry within 180 days after rhe aileged loss or injurv is discovered a notice stating the time,ptace,and
circtrmstances thereof,anr!rl�e amount of compensation or other relief demanded."
Piease complete ihis form in its enfiirety by clearly typing or printing your answer to each qaestion. IE more space is
needed,attach additionat sheets. Please note that you will not be contacted by telephane to clarify answers,so prnvide as
much infornnation as necessary to explain your claim,a�ad the amount of co�npensation being reqaested. Yoa will receive a
written acknawledgement once your form is received. T'he pmcess can take up to ten weeks or longer depeading on the
nature of your claim. lfiis form must be signed,and both pages completed. Xf someth}ng does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER D4GUMENTS T4: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CYTY HALL, SAINT PAUL,MN 55�.02
First Name,.��(: v►t�l fy Middle Initial�Last Name ���--�='
Company or Business Nanne
Are You an Insurance Company? Yes/ o If Yes,Claim Number? � ��)
�.. / d r rn�, R CX��
Street A� �� S � 5/, #/� �d C=�-r°( ��ra.h .,_..--_..�. a.,�.,�-�. � �.-
' � �54/0�
City �/1 i l� j2 '�-t�7�f i � State �YI� Zip Code -�
Daytime Phone(�,��(���ell Phone(^.._J Evening Telephone�) -
Date of Acci enV Inj ury or Date Discpvred � g� —� �� ime am/pm �IC�
�-Y �v v..1e� �� 5 t�'a;,�;_! �o/ic o lv1� 13Gc� Ld'f' �rq7�o;z��a-c� ��'�A/� - l
Please state,in detail,whnt occurred(hnppened),and why ou are submitting a claim.Please indicate why or how yo�
feel the Cit,y of Saint Paul r its employees are involved and/or responsible for your damages.
; y� '� � � r�. . �r�. � . -. � � � a e �` � ��v
c} � o l.c�.� 5, �'1' � c rS c .5ea�
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.�-:�,� CJ'� C=Gt��'�C �T j/) �>>.�Gt h'1� ' �r �D G C�j--� i w 6� 7��
��lease c eck the box(es)that most clos y represent ttze an for c mpleting this form: _ t� 5 d _�c`}�_
❑ My vehicle was damaged in an accident ❑My vehicle was damage durir�g a to ---�
❑My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow�-�c.�
�My vehicie was wrongfuily towed and/or ticketed ❑I was injured on City property �� �-_N��?,
❑ Other type of property damage-please specify ° �e�
❑Other ty of injury-plet�se specify/ ! ��,,,��
,�'c�'��� �'�'� C 1"fc�.`�t�+� c r��i�U:'� V E PY�.��t�!'� (i''2c.C.� r
In order to process your claim vou need to include co�ies of all applicable documents.� �.,��)�
1c,�ac�.,�� L.i��. 1^e.i M�u.r��MR.n� �Y�'� �b l.l:�� �'` �`�'�'g2�� � �,Lci^
F o r t h e c l a i m s t y Q e s l i s t e d b e l o w,please b e sure to include the documents indicate�or it wiIl dblay the handlin g of ��
your c13im. Documents WILL NOT be returned anc3 become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property da.mage claims to a vehicle:two est.zmates for the repairs to your vehicle if the damage exceeds
$SOO.OQ;or the actuaI bills and/or receipts for the repairs
�Towiag claims: legible copies of any tieket issued and a copy of the impound lot receipt
O Other property damage claixns: two r.epair estirnates if the damage exceeds$SOO.OQ;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims:medacal bills,receipts
4 Photographs�re always welcome to document and support your ctaim but will not be returned_
Page 1 of 2-Please complete and return both pages of Claim Farm
1�� ; ���.�,.�,1� �; z.e �
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Failuu-e to conciptete and retum botla pages will result in delay an the bandling of your c,laim. ���� ��Qs
All Claims—please complete this section r��" �
Vdere there witnesses to the incident? Yes No ��Llnknown� (circle) � ���
Provide their names,addresses and telephone numbers�f`� v`' " �� '� c� �
�,� ��d .2y `�'���
Were the police or iaw enforcement ca�kd?�z�'`�'��es No Unknown (circle)
If yes, what department or agency? `�"f �_ �� ;r.�.1 i�c-�_ Case#or repc>rt# �,��; y�r�: "Z`�� d�
Where did the accident or injury take place? Provide smeet address,cross street,intersec[ion,name of park or facility,
closest landmari:,,etc. Please be as detailed as possible. If necessary,attach a diagram. = °�-�
R.
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��' r z�1 �e���w—� ��� t�e-�
Please indic�e the amount you are seeking m compensaUon or what you would like the City to do to resolve this claim
to your satisfaction. � �' ' � � )
tL u u j ` .L5
�- � •.,� � �ci:� <tih � Fizh
�3�-��v f`'�"rr�v'� l'vt �=�.-�" ��f"h�� . C4:,ra!C���.r:`�.. d Zv re n Ca.�-l 5-fa,���
Vehicle Claims—utease connvlete thi�section �check box if this sectiQn dces not applv
Yoar Vehicle: Year�Make s���,.�c a.� Model �
�,{-� �n%d�'� License Plate Number �s�,�s—f��� State Color �
.y. � �r� w`` Registered Owner �c nt�(� K" L�--�-�
:�`l �` �J�,,n. �'' r�Driver of Vehicle ,� �.,1�/ ��/-� � t /(�o f o. Jv,c rin y 'v�-�''.o n�
�"1��� �yq��1./�z���9 Area Da geci
I°'� City Ve�'.�e: Year Make -Niodel
���,������-1--(►�J 4�,Ll Lzcense Plate umber �°"� State Color
�.�- (_t'�1 �_ �Driver of Vehicl ity Emptoyee's Name)
��r� i;,�, v}r���� ��Area Darna.ged
°� ���� In'u laims— lease com lete this s 'on _� 6�'ch k box if this section does no a 1
How were you injured? , 7�, -f f «�id .[.�. e.t- 1 s of�"� Fe -f a
�s rF4 cti�s�� .�
What part(s)of your body were injured?
Have you sought medical treatinent? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medicai Prc�vider(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 yau are attaching more gages to this claim form. Number of additional pages�.
By signing this form,you are stating that all information you huve provided is inte and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitt�ng a false claim can result in prosecution. Date form was completed �/ � L���
Print the Name of the Person whu Completed rm: ° v-� c� f � �
�
Signature of Person Making the C�aim: '
Revised February 2011
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