Abdullah, Rarity R��FI�/ED
MAY272014
NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Mir��.�t CLE�K
Min,tesotn Stnte Statute 466.05 stntes thcit " ...every persrni...whn claims dcintnges.�roni nny iriunicipalih�...slinll c•n�ise ro he��resented to�he
governing budy q(the mt�nicipnlity wiN�i�t I80 dcn�s nfter the cr�/e,�ed in.rs or iitjury is discovered u notice stntiirg tlte time.pince,mid
circumstct�tces thereof,ancJ tlre nntoeutt of contpensatinn or other relief demanded."
Please complete this form in its entirety by clearly typi�hg or�rinting your answer to each question. If more space is
needed,attach additional sheets. Please note th.�t you will not Ue contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amo��nt of compensation being requested. You will receive a
written acknowledfiement once your f'orm 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 pa�es completed. If somethin�does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CL�RK,
15 WEST KELLOGG BLVD, 310 �ITY HALL, SAINT PAUL, MN 55102
First Name Middle Initial � Last Name ��V1�\��
Company or Business Name
� __ _ _ _ _ --. --- --- _ �� �
. ..,�^rw.�ra�..—.�`_w_ _ . _
Are You an Insurance Company? Yes/Noxlf Yes, Claim Number?
Street Address ��� ,� �0(��\�,N� p��� ��V�� �►`
City �� State �� Zip Code_� "f u J
Daytime Phone ( ) - Cell Phone �)]�-_��Evening Telephone( ) -
Date of Accident/Injury or Date Discovered -�7 " �� Time �i�� a /pm
Please state, in detail, what occurred (happened), and why yo�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. -' �C ^
� ��N1�iC; C� "e �'b e !�� '.� r: t�-��5 ', ,� ' i i..f
��.i G 1' f t� «,-- ✓� . ,
S'',J A� -r- w„�i tV.� �- S c�FP T 7 �1'��r p C,.t t;� ��
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
�Arly 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
O Other type of property damage-please specify
❑ Other type of injury-please specify
In order to process your claim vou need to include copies of all apnlicable documents.
For the claims types listed below,please be sure to incl'ude 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 vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for�he 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 damage�ite;ms
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 complet�and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims— lease com lete this section
Were there witnesses to the incident'? �� No Unknown (circle)
Provide their names, addresses and telephone numbers: �(�,V�� C�YI(�(�1W�G�
�I�)q �`�Y� �U�('., Sa�in� 'P�N� _M�j o�1 3�-t'7 4�"►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.
Please indicate the amount you are seeking in compens�tion or what you would like the City to do to resolve this claim
to your satisfaction. �
_ V��hi�l�� CI�im5—nlea�e c��c�te thi'�sectinr! _ _1� ' �7 che;.k hox if thit secticm dc�es nnr f�nniv �
YourVehicle: Year Make __Model
LicensePlate Number State kW Color 131�
Registered Owner
Driver of Vehicle
Area Damaged
City Vehide: Year Z�b�i Make , Model �;�' ,r�j�►I�
License Plate Number �.� State�Color �W�
Driver of Vehicle(City Employee's Name) C.aJ�D�Gf, F��rl�� c� Rar-���4����i\0��1' �►{4.�►
Area Damaged £r�.���__ � �
Iniurv Claims—please complete this section ❑ check box if this section does not applv
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatrnent(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))
_ --- 1Vame_nf v�xir Fmnlo,yer� ._� .
Address Telephone
�Check here if you are attaching moi•e pages to this claim form. Number of additional pa�;es
I3y signing this form,yoic are stating tlaat ull information you laave provided is true and correct to tlae best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �'� i�
Print the Name of the Person who Completed this Form: Q�� L ��
Signature of Person Making the Claim: � o�
Revised February 201 1 ,
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