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RECEivE� APR 0 2 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Mir(dle��t�LERK Minnesota State Stan�te 466.05 state,s that"...every person...who claims damages from any municipaliry...shall cause to be presented to the governing body of the municipaliry within 180 da�s a,�tecthe a7legedlass nr ittju�cis disccu�ered¢notice sta!ing the time,place,and circumstances thereof,und the umount of compensation 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, MN 55102 First Name t" Middle Initial t-- Last Name ��`�'J Company or Business Name Y� � � �UC�C(� � �tl��a'Y')� �`�C��� �lf'�C�� ' c� �cl Are You an Insurance Company? Yes/1� If Yes,Claim Number? StreetAddress �'-�1:�� ��SSr:�i(Y1���1� ��i('_, l�C�'� �1D-t, ��1� City_��r�fi 'P c�U 1 State 1�1'I� Zip Code �� Daytime Phone J`i)��- �'`�11 Cell Phone(�_},?5� -3�`I� Evening Telephone (�)�S�`1-33-f I Date of Accidend Injury or Date Discovered��Yt.�'1 �=� :�(��1� Time ����M am i�pm Please state,in detail, v��hat o¢curred(happ�ned), and,ct�hy}�ou are submitting a c�aim�_Please ind'cate�vhy or ho�s�yo�, feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ��'i v�v�, -i�` („�n►rlc,�r;,vn,,t� �t r�[� (1uC1_� �vi�i�l (',�C� t�'1 �VZ��lt c.�%1'JCYltr�cj /�t"b �t�'ZP�K�E' C�` me T Ir�� t � �.xx:�c h��c �.�{��c,n �-c,� �v c t�rc;,� s� -t ��a.rw����11 ezF,c L U'ru-p i� --te r�'i SYY.i,�n�i GnLj hCJ ��7 .51-rlCti�Y, 5��tt. '� G� �4��oe'lcl �•i- C� _ —� � —�[,� :�����-�-►�'� cY> r( .} i•t •'(1� '�Y1C�j� l.tiY1a�C C�C:-c`� -Ct�c"'r �T C�iSC C:U�� �'Y�'�C. 1"4'1�1 � ' {�� r " �' C�G , ° tJ"Yl `��Sclr. �c�•1- rn.� �ar t� -.ti..-� Grr. ('V.x�ct �lh2,r� �v e �v,r�r+`; t�t'FiC%eS :✓� tfieCvea c1�� fic� IA:LCt•�hPl� C� /k{�C"iv^1 K?�:r -4�l1C C,'� � ciF' 'S:a•-�t C�:ta� SYl(:�td 1!��' G�"�"l e�ls E Yyr,q '►�G'"t�J `t-yYZ S�vC�,��, Pleas check the box(es)that most closely represent the reason for completing this form: �.�3 �('-�;e ��T i�•='y �on,�,c;ne ❑�vehicle was damaged in an accident � My vehicle was damaged during a tow �'�c rr cr.�r IS7�My vehicle was damaged by a pothole ar condition of the street ❑My vehicle was damaged by a plow�'�t `��`"�«�� ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property �S n"�+, ❑ Other type of property damage-please specify � ,,�,���� b� �apry ❑ Other type c�f injuiy=�l:as:.sp.:ify_- _ _ _- - - _ _ _. _ __ _ _ - - _ _ — _<� Y.F��-��p ir �-c�'� Cxn s�.�e,+ In order to process your claim youu need to include coqies of all applicable documents. �� r�,,�Sd���,�s� For the claims types listed below,please be sure to include the documents indicated or 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 vehide if the damage exceeds $500.00; or the actual hills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims: two repair estimates if the damage exceeds $500.00;ar the actual bills and/or receipts for the repairs; detailed list of damaged items O�njury claims: medical bills,receipts Ql Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2-Please comnlete and return both na�es of Claim Form 1 . Y � .� _ , , � .. _ . - - - ��_ �. . I - _ � : , � - -- - . , . , ,. � , .. - _ _ _ _ _ . . -� �- . . _ ., . . , . _ . _ _ ._ - - . , I y�;• Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease comnlete this section --'"` Were there witnesses to the incident? Ye No Unknown (circle) Provide their names, addresses and telephone numbers:_�jfx5�x1 (Y`��[��'" j'�;uC.} ",��'r�n�rK S �1,)t �/� "��i�� �,2`�4`� �_ ��r�l��v �=�1 i� T� SZ�c t 3 � 3i����`��. �l,rt'�^�i Were the police or law enforcement called? Yes No Unknown (circle) If yes,what department or agency? �l�.L,� 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 dia�am. �X���,fi�;ti �L�V�. E �rirv���l StrCC•k . . Please indicate the amount y are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. 1 �:_�"' TC> , �C"C��"c,lC.� -��' Yi vr Cis'� �"t�"� $++�E'_ � �;�yf���, �'-�,°�,_�� ;�.,��r��.-�-���i Vehicle Claims-please comnlete this section ❑ check box if this section does not applv Your Vehicle: Year .�T'; .x Make ��,v��i�'� r Model {�rCr����V License Plate Number State�Color S:i v��" Registered Owner �y�� L. �`�l Driverof Vehicle �luSS� i-. 5t���5 Area Damaged �.��� �� rvh�t e �Wi-�r�l�l ' "'s"�r� Citv Vehicle: Year Make 1�,1o�e1 � License Plate�i�m�ber- �- -- � State -••• �olor- - - � Driver of Vehicle (City Employee's Name) Area Damaged Iniurv Claims-please complete this section check box if this se;,ti�n d�:,s not appl� How were vou inlured? 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 to this claim form. Number of additional pages�. By signing this form,you are stating that all informatinn vnu have nrovided is true and c�rrect to the best of your knowledge. Unsigned fornzs will not be processed. Submitting a false claim can result in prosecution. Date form was completed_ ���� r l �� .��� Print the Name of the Person who CompletqEl this Form: � 1 �� �� ��.. , °-�-- �. � _ �� � � �;,� ��� � Signature of Person Making the Claim. Revised February 201] 3/20/2014 image.jpeg .. _ + �.-. „,.�.,,r,w�.�� ,. ,... ., >, , �� � �'��.. 4, ._ -.; !� . _,_ �.. 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