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Cartharn, Jeffrey RECEfV�p MAY 2 8 2�� 5 a�- i� CITY CLER� This claim form is being returned without having b�een's�t up as a claim for the following reasons: Failure to provide a written description as to what happened and why a claim form was being submitted (page one). �Failure to provide the proper and required documentation(page one). Failure to provide a date of accident or injury(page one). Failure to indicate the amount of compensation being sought(page two). Failure to provide information about the vehicle involved(page two). Failure to provide information about the injury claimed (page two). Failure to sign the claim form (page two). Failure to print the name of the person who completed the claim form (page two). �Other: ��(�� t'��'�Zit� �� C�l�l/� ` _^ � / �itJ.�� C��I�r �"7v � �� I I`C'r'S: -�. �.. �Cx r, u � Please return the completed clai�to: , ��J r� .S /r��.� � -� � /Z, C-�..�- � Office of the City Clerk City of Saint Paul 15 W. Kellogg Blvd. 310 City Hall Saint Paul, MN 55102 If you do not return the completed claim form with the appropriate documentation or - information completed, then a claim file will NOT be established and an investigation WILL NOT be done. In other words,NO FURTHER ACTION will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances. REC�IVED RECEIVED MAY 28 2014 MAY 09 2014 C I TY C L��CE OF CLAIM FORM to the City of Saint Paul, Minnes�aT'Y C L E R K Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shaR cause to be presented to the governing body of the municipality within 180 days after the ulleged loss or injury is discovered a no�ice stating the time,place,and circumstances thereof,and the amount 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 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�e Tr�� Middle Initial Last Name L�ti r �-��Cti r� Company or Business Name Are You an Insurance Company? Yes N� If Yes,Claim Number? Street Address�1�'�� l�C' r �� City I�(1`��:�C'1 C:�l�. State ��l r1 Zip Code •� Daytime Phone( ) - Cell Phone(�.P4��)�- ! � Evening Telephone( ) - Date of Accidend Injury or Date Discovered �-'� � " I y Time . ' �` am/� Please state,in detail, what occurred(happened),and why you are submitting a claim.Please i �cate why or how you feel t e City of S � t P ul or its em loyees are involyed�u�dior responsibie for your dainages. �j� '�n � rF �+ ��Q � � i�t,�n � c;�;►�o Cxrea Please check the box(es)tt:�:^:��:c?c�e'•;':eY=eser::-".�=�s��"f�;�`�""Y��'"b�"=��°=�": ❑NI vehicle was da!Y!aaP.� in an ar�irlPnt ❑ M}'Vet?�r1P wac rlamaooPri ri��i�o a�n�r� yo-- ------------ �My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow u - �,�_�•�P ..,�� r„��.,f�..<,P.a .,�,ai,�r f:��'.:�ted � i.,,as i.^.jured on City property �i vi i,ivi j f�C.vi t��."��fn.iy:ui�Fige-please specify .--.___._- ❑ Other type of injury-please specify .a ♦,. • ,.l__.7.. •..,, r,.11 ._17,.._t�,. .7,.,.._�..�a.. In order to process you;C+�Qilll yVLL 11GGLL �V 1R2��-�-VN�!•�� n!! P��'��u�~"��r�� ._ ..l_� 't':_"' `_..",. 1'_�_J t_..l_"' .'1„�' I'.. '__"' `.. '_"/".l_ .l_.. .l_ �._-�'__•_•1 • __""'__"��_ ....:a _ ::.... ...... ....,,. ......-. .._.�„ „�,,,,W. �,,��,� �� ,��.,, ,��..�,,.,o�.��,,.�,.,_,�,��., „�.,�,.��.�� W�il �ielay the han mg o � � . ._��T T l�i/�Tl" _-_�1___'"'__ `l_' _ ""'"__".�_. _Cal� .♦ \l.." _"_ -",_..,... �__•:iiu. _°_____ _:-t� rr 1L1.i�vt vc iciuiiicu cuiu ucwuic uic Yivyci�y vi uiz Ci�}�. i�u aic cii�vuidgeC110 eep a copy for yourself before submitting your claim form. • ... • ....,. - O Propc .. ,.._� .. ............. .....:_.....�r.. .L... . , ..... .. .... .......... .. ... -- - ...._.. _,._..._.. .� ..,. ,.t.,.i_ .r. ..._. .t,.....,.�,, i , __._. ,�i.y unu�na.. ........... ... .. ............ ..... ........ . ... . . ... . Q`c /�n. t,. ,.,..__..i t.n,. .,_a�..____,.._«.. c.._.t' ---._'-_ .P.JOO.VV� GI IIIV QVI.UUI Ullll G114�v� ��vil.�..iv� t>><,��j.e..... 5 O Towing claims: legible copies of any ticket issued and a caYy�f t�c;;,��,:,��nu 1ot r:.c�i�,� n ", f�;! n �«w,,......,._,. .. a,.......,.,. ,.i.,....,......,._,..,......... ............ :c.w,, a,...,,.v,. ,...,.,.,.a,, mcnn n:.. ,._��,�r1,�1�h1T1S , .� � � __... _- =:.__r=_ � - - � ---..._... ............. .:... ..t�amaged items ___-' '_' '_'_ _'r"" ' "'"'_'......... ... ^ ��'�•�• ��^�:::5� :::P�ical bills,receipts ... �.J...J ... . '' � .� �.� . . �. . ♦ . i . 1. 1 ._ ' '..... ...-..�. . .;..�� .��i .�i�� .�� .r i'r�}ilTT1P . . . . _ . . .\ • .. l. � . •11 .. .. � .....� .... ._..._...� ._.. .�.�..�.... ........ ...... ... ... .. �..,.. \i . .. . ..-`" � . Page 1 of 2-P��.�..,,. -`��.,..��.�:�_.-.�:;:: -- -._., �`�-..__==r:.===_ �-r� Y"a- Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease complete this section Were there witnesses to the incident? Ye �' No Unknown (circle) Provide the' na es,addresses an� telephone nu bers: ka��C�1� �'u►'�}-Yla�'rl ti�� . c�v.� I �1` ,r��l-� l� ►a �a�t -��i�7 Were the police or law enfarcement 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. �vlQr I�{l 4, Lu��:. Ct��Ca �nSV l ��n�� 2�c � t�r��rr�� -./--�vcrn�; �� t-� 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. VeWcle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year aa � Make Model "t 1 � TPb License Plate Number� State�fl Color Gt C IZ Registered Owner c' ��` � +' �- Driver of Vehi P Y �1-�1 Area Damaged � (1 City Vehide: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged iniurv Claims please complete this section �check box if this section does not avplv 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 attaclung 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�'��' � + Print the Name of the Person who Completed this Form: � `��c�r Signature of Person Making the Claim: `c Revised February 201 I � _. �; .�..,��.�__,�a��s_-�.m.,.�:_-�_._..��...��_,_�a_.,��_a-<,<�m,.�a_�«�..,.�o=,n,.n..o<.�.._,<n��<ebT�,��m�,°a<,.>a,o�,a..�,_.<<�,=,a�>.p>� �� Q�� 800QER �EL ALIGNMF.II�T, III�C. FRONT END 8 STEER/NG 5PECIALISTS • COMPUTER HIGH SPEED WHEEL BALANCING � � DOMESTIC • FOREIGN . TRUCK • RECREATfONAI VEHICLE t� COMPLETE BRAKE WORK 207 Lowry North MINNEAPOLIS, MINN. 55411 Phone 612-522-4489 NAME _�� AooRESS__ PHONE �AT€ y� .N N . M A 1 �/�+7 //�{ �<'7 ..� / ('��— ,+' , � � e� �� 1..,,•+C,t/�! � / "i-� /� ,/�V1 I r �� '�e�` �r� � �`� / C' I"'� �f�� ° � , � � QUAN. IART NO. NAME OF PART AMOUNT ESGRIPTION OF WORK ' AMOUNT _ WHEEI WEIGHTS - WHEEL A � �'' `��'' BRAKE PADS SPRINGS BRAKE SHOES BALANCE WHEELS SHOCKS SHOCK ABSORBERS McPHER.STRUTS TIRES ROTATE i BALL JOINTS �,7 STEERING GEAR TIE RODS ,yc� IDLER ARM �.'�'�, ;,,/e J �-7' � -'•- � •��;. ,� IDLER ARM 1 ��• ,� TIE ROD ENDS ____ __ CENTER LINK CENTER LINK _ ' PITMAN ARM fc„' BA�L dOINT �=?' �.� �,. � ,,,�r / �� ,� °f � � �..�� i p ;� �' PACK FRONT WHEEL BEARIN �• �- •� SURFACE ROTORS � �� `� — "-- -�— SURFACE DRUMS ---"� CALIPERS °; � �� - INSTALL STRUTS � PITMAN ARM __ ------- — ----- ' -- , _- ( �' �� ,�.'� � �'-��: ..�..:> , ATT: R�TOR�UE � `'� LUGNUTS AF7ER — ------ 100 MILES ON A�l.OY WHEELS TOTAL PARTS e3 __, TOTAL UBOR �' ° ---- TOTAL PARTS ra �" L' ESTIMATES FOR LABOR ONLY - MATERIAL ADDITIONAL