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Colas RECEIV�D NOTIC'� O�' CZ.AI�VI T'ORiVi to the (tit�of�t Pa�l,lVimn� 2 0 2014 .� �.��.�m"--_���-..,�+�e����� =-..��,�a������� - aadyr a�t� � w�,�d�ps a�er�r�la�m.a�y ia�C,ar�nrr,a a,�.�r�C awr pr�,a� esre�ast�ccs�I�f�r aw�o�Teowpr�wa�i�r o+r�er seiie�dlr�dcerd." Ple�c c�lclt tiis fir��iLs�b�dearl�t�vl�l��l�r�6 3���e�c��es�. H�re a��eee a �edci,,a11�i aiiti�l� lfea�c rtc 11tiat�w w�i Mt bc n■tsdai ir��i�■e�e��sa�sQS,sr�iie as �ri ifir�ati�a��t�e��iai��c1aiS,a�i rie a�■�t�f d�e�ati�bei■�n�e�ei- l�w w�i reeeise a wrri�e�ac�rwie�Nce�s�r far�is r�i. Tlre�r+�or�cs ta�e��iea w�dcs sr lr�per ie�e�i�N�ie d�+c�f�+wr cl�i�., Tiis fir��a�t bc ai�ci„a■i ti��es a�i�i �f s�dii�i�es�t a�iF�w�ritc`1�f/A�. �D C� I�ORA�AIl�D O�DOC�,�fl11��"1'�'T'0: CT7"Y�� 15�,S"r'K�LOGG BL,�D,310 C'IT'Y HAL�,�AIfl11T'PAI�LL,flVll� 55102 �It AUam� P�-�/� 1kI'iddl��itial _� Iasi AAune �.c� ��5 C'o�mpan�or Bnsane�AL�o� Ar��ou an 1�ane�e Ca�g? Y /Alfa Y'�,.C�m A➢ambe�? S1�r�r� Z �-��� l.Q ��',' ��- . �p �� Z � � C�it1r `l ��r,� � �`�,,Ps,/ L�rtJ,-� S'�ate �`n � Z�p C'ode � l 1 � n�����-. �irt �n r� u.� l���t�i�3�,��� �,�,� �-`���� I�af�jnjar�r or Dr�tt�D;��d �Z�=�� -�.v t� T-,��1�>���'-� (amJ"pm Pf�e state,im detail>w�1t occvrred(ha�peaed�,aod�1r�a�e s�nbmitl�iog a claim.Plcase mdical�e�r or 1�� fe�l the C�t�r of Saintt Paal or its�m�plo�es a�re in�ol�ed aod/or respoa�ble fvr�oar�- �,, � f 1-��-� �. \ , - , ��,�- � � ; ,� f � � " Uc � �'S � � i - P1ea9e�1�bax�e��thaft most do�el�rep�t 1�r�on for cvmplel�ing 1�fom� ��r�ehicle�cas d�ged'm a�accident �A�r�ehicle�x�as�d darIDg a tov� �11tI�r v�cle wa��ged b�r a potliol�ar c�andition af d�e str�C ❑DI��C�rehicle v�ras�b,�T a p1ovR �AcI��Wras warong:fall�t to�d aod/or ti� �I�ra�inja�ed on�'proPe�rt�' C1�Other t��pe af'��e—Plea9e�f�r�`�`�l b�K�'S � Q v Sk S 'C��mv���,� ❑Other t�pe of i�ar�—plea�� �n o�der to ptv��onr clanan��d i��ci�d�c�ovies a�f a�avvtica�Ic dec�. Far t�he�laim�t�li�d be�sr�pl�ase be�me to imclade tlhe doc�ts indical�ed or ilt v�ll delap 1lhe i�ng of g�oAmr cla�m. Docum�s�itTI,L 1�IO�T'be retmrned�md become the pro�ert�o�'1lbe�. Yaa are encaomrag�d 1to�eep a �for�rour�elf befior��ttin��am'claim fasm. O Pr�npe�dama�cla�1to a�icl�:t�^o�for tlhe repaiia�to�varc vehicle i�Uh���eaeceed� �5�0.00;or 1►he actnal bi71s and�/ar ree�p�ts for the�r.pair� O 7'owring cla�ms:legr�ble cop�es vf a�g tic�et i�d aod a cop�o�the impoand lot�plt p ptiher properlt}y damag�claim�_tt�o iepair estima�e�if the�e e�ceeds�.5�.�or the actnal b9D� aod/ar�far the repairs;dela�d lislt of damag�d itcmn� ��n�t claim�:�1 bi71�,� O phaltogxa�a�alv�ys�k.�me to doc�me�amd�ort�oar claim badt w�t nolt be r�tarne�d_ P�e 1�f 2—Pfe�c�e aa re�s b��ea of C1ait I�er� 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 Unknown (circle) Provide their names,addresses and telephone numbers: �fv�uk ��i �S--t�-,.e _✓ ���\ �Y-.� \,��,-, ���P�� . M ►.j ��� ��� l��S\ - �-�i- S�-�� Were the police or law enforcement called? Yes No 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. � C i\\ i- r�-.��,i�h �-� ">� `�7�A..L L � �l�i �S \�lr� Please indicate the amount you are seeking in compensation or what you would like t�City to do to resolve this claim to your satisfaction. l��nc%lc��-„�.�5 � `�� i�1 L,��-�- ��r,�.�� � • r.�r� `� 3Z.1 � `-�'-- �[� l-�A'Y'��l-�.� � Y�e��1�[?�rc`��Z- ��Y=�Y1r�t Yh t,(� 1�(�-� ` �L�`��S � '��1��� � �CX- X ����� . \ wv��� �1�,�. {� � V��?ii,��vt+/��/`� ���'`�-' ���'�'�,}��-S • Vehicle Claims—please comUtete this se�tion i�check box if this section does not anplv 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 Iniurv Claims—ulease comnlete this section ❑ check box if this section does not auulv 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 �heck here if you are attaching more pages to this claim form. Number of additional pages l . C � � f�1cv v G S (�cC 2 L Y3'�1�t�C U�n Br�Lt.- � �� � � �C'-�,.�:C�j .� f"\.t.�.�.J By signing this fornz,you are stating that all information you have provu��tr�'e 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 � Z���' ' �'�'� �i 3" � "zo�`� Print the Name of the Person who Completed this Form: ` e=v"� �.,t� � Ka� Signature of Person Making the Claim: ����'�-- �y' Revised February 2011 Belland Handyman Estimate 5743 Auburn Ave 100457 WBL, MN 55110 651-785-5573 Date: 3-1-2014 Customer Information: Billin Address: Shi in Address: Company: Company: Name: T2�I COIaS Name: Ada��: 1511 En lish St Address: City/State2ip St PaUI, MN 55110 City/State2ip Shipping Method: Order Information: Product Descri tion Amount Each Amount Labor and Material 2 Remove dama ed mailbox osts and re lace 75.00 150.00 2 Remove dama ed mailboxes and re lace 75.00 150.00 subtota�: 300.00 TaX: 21.00 Shipping: Grand Total: 321.00 Notes: Additional Information:Sales,Events,Conditions of Sale,Warranty Iniortnation,Shipping Options or other policies can be mentioned here. . w.. _ R., w ...,u„�9�m 11�+��,y!y � ku .� . 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