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Thao, Tong NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Mrrrnesota State Staaite 466.05 states t{utt "...every person...who claims dnmages from any mi�nicipaliry...shall cnaase to be presented to the governing body qf the municipality within 180 days after the nlleged loss or inji�ry is discovered a notice stnting the ti�ne,place,nncl circumstnnces thereof,nnd the amoimt of compensation or other relief demnnded." 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 IVame ��n�1 Middle Initial C- Last Name �� I V E D Company or Business Name 2 9 241� Are You an Insurance Company? Yes/ f�o If Yes,Claim Number? Street Address �7� �a rl S�`, v�� C�E�K City S�i r �v� State /�� Zip Code ss �� 6 Daytime Phone( ) - Cell Phone(�6 3 )�yZ-S o�l S Evening Telephone( ) - Date of Accidend Injury or Date Discovered 5 f Z f��c 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 respo ible for your damages.���d `,,1�7�[sl�—�aC , + �-b 1V`d�1�1 B � �� � � k� � , — a , � a s na irh of- I. 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 property damage-please specify ❑ Other type of injury-please specify In order to process your claim vou need to include copies of all aqplicable documents. 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. roperty 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 the repairs O Towina 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 items 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 result in delay in the handling of your claim. All Claims-please complete this section Were there witnesses to the incident? Yes � Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement 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 facilit , closest landmark, etc. Please be as detailed as�ossible. If necess y,attach a diagram. (�!1 r?��d �}�d- ��'„� —r� ---o f.7-1't Ul r Please indicate the amoun�you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction.��� Qi N1ovh-�- � Vehicle Claims-alease complete this section ❑ check box if this section does not a�plv Your Vehicle: Year�_Make �,G'7��p� Model 6 License Plate Number State ,MN 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-nlease comalete 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 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 �QCheck 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 will not be processed. Submitting a false claim can result in prosecution. Date form was completed �1�l �� Print the Name of the Person who Completed this Form: ��� Signature of Person Malzing the Claim: Revised February 201 I � ouN � v sc t T1 R E ,_�.,�� j �;�_ ._ _��.,�:�.�-_�� discounttire.com I,.i"'I I G a Y..���`—Y.�L—t_��i.� �T i} �—��4.�. 1 f'?L_e i"�� � �• � �• � �� � � T 1 �'�fJ1.�"i i'�1-�i��� f'�I'��� 'i�� �(li'(::; �^F�t_ =F7�i �i=i'`n'f_ '�i � -,°-';1 (•lHTT�' Et��)�+ A'.'EPlIJ� I',, c_t!ti ,. ` u, f, f 7—I MC�H I �!Ai��!E',�J+�r;�� i�ti�d C�i;i�_a `?€k!e;T F's=1U! l�ih! °`�1�!c F'HGi�:E: c��i-7 i�—��}6-i 4H:; �7�,y;—�'4c—����'�`_i �� i�'LHi�E # `�4�c�—Gh�l :t�3'3 TER�!Ei�1G� i�1 ��:1'fli TC�RG?l!E ��'�CS� V'���[� E�1QRK. 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LEFT FROPlT TD SF'RRE. COMMENT: BOLT �ATTERN: 5-f14.3 �7;4� NRM 1 215/�0R171(L '35V B ARIZDNIAN SILVER EDITIDN .Q►Q� 111.r�Q� 111.�D�b WARRRNTY: MILEAGE- 50,00� SEE REVERSE SIDE FOR WARRANTY DETAILS C�MMENT: INFLATIDN F:32 R:3� 80�17 NRM � CERT I F I CATES FOR REFUND,REF'LACEMEIVT .00 1�.�0 75.00 Since yau have purchased fewer than four tires tor wheeisl, we will �ount the new tires on the rear of your vehicla for best safety and handling. I hereby certify I am the owner of the product presented for warranty claim and the product described was not invalved in any accident, personal injury, consequential daoage, or other loss. I accept this ad.justment credit in lieu af other claims. I agree the product returned far replace�ent beca�es the property of the product ■anufacturer. SUBTOTAL: 75.Q�0 TAX: 7.91 TAJ(f REFUND) : -7.�1 TOTAL: 75.0i� XXXXXXXXXXXX 50�0 VISA: 75.00 TENDERED: 75.Q�4� 5ignature on file �� i 00% recydable paper ���:,,. ��� ��� � �� ��� ��� ��`� „. �� � � `�° �_ �� ° � �` �. • h�'... . ' � 't iF i�. �. L 'F i� �- �`•' � L �._ - ` '�', §:g .:�{ � "� .. Y �`+��~ � '�s�'c ,^-: � '�. . . � � S �'�.- ��x � ^� � *?: ..,,.:.,�wrt �.e_=��" c�=�y� ���. � y�� �� � "e��'�' .v � t� �,.fy_ �`� P .' ��� . �"' d•� ��� �,a,1 i��' � ��;# x j S� y '1` }.,q�� _ ��Yl�4- .�yt"'�,:y,`#t`� �� y�W Z ; y� ,e .n , ._a �'�" ��' '� .. tF , �'��� — � �' '-. `Sf. � �°� . . � ti. �� t �'►�€' � �`'`� x � '. � � ; .� . �yF �;r;x`z. �.i["-'- ,r, _] ♦ ._ �*r..'`�'• ti.����� � � ` � ''� � . , ,; . � •�i::+'..: .rr "34 ;� _ .� f. , �� . . *a�,.. ...t� � � �_x� �s ..�'� � ~� . . 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