Walters, Casey ��c�oe���
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NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�o�'¢Y C�.��K
Minnesotu Stute Stutute 466.05 stutes thut"...every person...who cluims dumages from uny municipaliry...shuU cuuse ro be presented to the
governing body of the municipulit��within 180 days ufter the ulleged loss or injury is discovered a notice stating dae time,pluce,and
circumstances thereof,nnd the amount nf 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
muc6 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 L'A5�`I Middle Initial$Last Name <<�AL'TF��
Company o:Business Name r OG i � �¢ �o �
Are You an Insurance Company? Yes�o If Yes, Claim Number?
Street Address l 1 J � L/41G�1UOi2�,CC(L/r
City L�ao n�ulzN State �iV Zip Code .r5/Z�
Daytime Phone((e�t) v�-�Cell Phone ( ) - Evening Telephone S7_)��Z�Gz�
Date of Accident/Injury or Date Discovered .�u..c�C Z.� 20/�l Time !o.`5S am pm
Please state, in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. .� f/�'T /¢
np�r�oc� Ar yzoo c tI a�x) tJ,c�ca�v .4v� -TwA�r .5.�r,�T>nE D ius� rir��
iit���Di r �y G�A��Er� .�L�13�iL� �JaL��S �U REOD�;N� /�7�'!iD�� F
/�T 1�.�.-�'ALG�b Yd hF .t�CoG /
�4 .UG/v T/�{E Z .�lAb �LI�L'Ni4�T� �� T'/� i Jlo 2O/3�. T•,�� T/%/G
G C O 7 'n � T�l
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Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
}$My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
G Niy vel�icie was wrongfully towed and/cr 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 applicable 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.
� 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 receints for th����3irs.
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 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—nlease comqlete this section
Were there witnesses to the incident? Yes No Unknown' (circle)
Provide their names, addresses and telephone numbers: ��,�icD2�•v r.c)A�7'i.c7� ��
SGNaxBuS
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency?� Case#or report# ill A
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. �'7�a Cv��sor�) t'f J�
C��30� � ��o��C�t�; or' z�og u���sz� •�����i�3.�.9.ey�
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. .� 1'7 O� (�y C�5 i �d�A .U��c7 %ilZr�
Vehicle Claims please complete this section 0 check box if this section does not applv
Your Vehicle: Year Z�� Make /I/)Azl�e'I � Model 3
License Plate Number_S�i3 C.W L- State �lil� Color �.�s�-,rz� ���
Registered Owner /�G�EtZT ��G,rl STa
Driver of Vehicle �b��l �A�T�Q`' 45PoU5�)
Area Damaged F�a,v� l���sE.t7lo�i� %/LZ�
City Vehicle: Year Make Model
�� License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please comAlete this section �check box if this section does not apply
How were you injured? n 1f1-
What part(s)of your body were injured?�lA
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
1�1.Check here if you are attaching more pages to this claim form. Number of additional pages � .
By signing this fornz,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.
� Zo��
Submitting a false claim can result in prosecution. Date form was completed -���� ,
Print the Name of the Person who Completed this Form: �� 5�� � ��G-��-''�5
Signature of Person Making the Claim��QOOi �C � G� /P��
Revised February 2011
�� i
1021 MAP ��J00D. MN
MAPLE3i . h�lA5�i 09
hIEMBER 111813718040
TIRESNOP QRDER � OO1Q2i0Q63531
VO1� PRICE VR
580769 2Q5 5R16 '95.03-A
PRICE< OVRD
580769 2U5 5R16 107.99 A
PRICE OVRD DIL SER/PK 2.99 A
SU6TOTAL 15.95
R 7.1Z5� TR 1 .14
TOTAL �`
VF Am�rican x�r'ess _1� N' ,¢�ilo<.c� l�s�/i7 <f,�>>',� G�7A.��j.U7�/ --��i�;���-
---_=--=_--_ �_��- - - �
XXXXXX?SXXXX1019 SWIPED
Q6/43/14 t7:21 �
Se9�: p00U24 AP� : 522771
American ExPres� ResPC AA
Tran ID�: 415420 2000
Merchan# ID 9910 11
Af'PROVED PURCHASE
qpI0t1NT: 517.09' .
1421 Q95 0000000813 4045 .
CHANCE .04 ,
TOTRL NUMBER OF ITEMS SQLD = �
�1 i��ijL a�a�K 1421 95 Oa45�$13 � . '
THANK YOU !
PLEASE COME AGAIN !
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