Kretchmer RECEIVED
APR 0? 2014
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages frone any municipality...shaU cause to be presented to rhe
governing body of the municipaliry within 180 days after the alleged loss or injury rs discovered a notice statueg the time,place,and
circumstances thereof,and the mnount 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. Ptease 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 w�71 receive a
written acknowledgement once your form is rnceived. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and bo�h pages oompleted. If something dces 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 N� c�i� Middle Initial�Last Name�Y�'�Z,1'�1'YlQ Y'
Company or Business Name
Are You an lnsurance Company? Yes� If Yes,Claim Number?
Street Address�� C� �� �. � �u�C'
City � ' p�-1.�.� State m�i Zip Code��L
Daytime Phone�) - Cell Phone��-u 1 l�yEvening Telephone(_) -
Date of AccidenU Injury or Date Discovered^e�"��' ��1 Time �`�� 'am pm
Please state,in detail,what occurred(happened),and why you are submitting 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.
Y c. b l -
CZ � `�
�
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 pmperty damage—please specify
O Other type of injury—please specify
In order to process your claim you need to include copies of all apnlicable documents.
For the claims types listed below,please be sure to inciude 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 velucle 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
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 iteins
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 msult in delay in the handling of your claim.
All Claims—oleage comulete this section
Were there witnesses to the incident? Yes No �Unla►o (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unlrnown (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. `v�vi �u�TbbC�'?�t 0�
\n�a,+�p.r 12s� ..-h-�'� �'i� t��C-���4�,► �ds p� .
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicl — 1 com 1 ' n ❑check box if this section dces not a 1
Your Vehicle: Year t Make�,�9�-r Model
License Plate Number �q� �11 L� State j�p�Color 6U�t��
Registered Owner �C�Y1SL��O�SI
Driver of Vehicle 1 r
Area Damaged�,fi -1QQ SS�A'L�Y �A)�0.�` Y�C.
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In�urv Claims—olease comnlete this section �check box if this section dces 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 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 information you have provided is true and correct to the best
of your knowledge. Unsigned forms wiU not be processed.
Submitting a false claim can result in prosecution. Date form was completed o�" a y � � �,'
Print the Name of the Person who Completed this Form: ��J \�- 1'�
c /
5ignature of Person Making the Claim:
Revised February 2011
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