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Connelly, Kelly (2) v � N l GK� S IZ 5 a N� i��i�7 ��C��Efl C�-s� 32_6�c� JUN 13 2014 ��l��D NOTICE OF CLAIM FORM to the City oiC��t��ir��2�'4 Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall ca�e �e�reEe�jt�p� governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice 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 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�t��` Middle Initial � Last Name �a �n�1� . / • Company or Busmess Name a� ��/�..J�c-�t. Are You an Insurance Company? Yes No If Yes,Claim Number? Street Address ��` �.a.� � s:h. �� " Lc.:r�� 1'�.1 �r�v� T�;.�\ City � � �..��C� State '"[� Zip Code �SV 6� Daytime Phone(�)�- 3�SOCe11 Phone( ) - Evening Telephone( ) - Date of Accident/Injury or Date Discovered �� Time am/pm Please state, in detail, what occurred(happened), and why you are submitting a claim.Please indicate hy r how you feel the City of Saint Paul or its employees are involved and/or responsible for yo r damages. 01� o 'p �/ � 1� So\ 'C eM � �/ . ��C e. w , `' :�, � � S� � �,�, • , r ^ l � s ; �- r.J �=,� s 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 O 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 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. 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 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 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 I Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comulete this section Were there witnesses to the incident? Yes N,,o/ Unknown (circle) Provide their names, addresses and telephone numbers: 1v� Were the police or law enforcement called? q Yes No Unknown (circle) If yes, what department or agency? �/"1 Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,n me of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.�� Please indicate the a ount you are seeking 'n ompensation or what you would like the Ci to do to resolve this claim to your s�tisfaction�� S► +O�-( .M �' oS'� v• �t�c., ,h` Vehicle Claims please comulete this section ❑ check box if this section does not apulv Your Vehicle: Year Make Model License Plate Number State 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 qlease complete this section ❑ check box if this section does not apnlv 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 will not be processed. Submitting a false claim can result in prosecution. Date form was completed�1� Print the Name of the Person who Completed this Form: ��i�\i/ � � �' � Signature of Person Making the Claim: Revised February 2011 � -j�J - �at,c� }3 C�� --- �� `��,�lt�t��i��f�f�,�,� � _ �: Wisconsin aepartment of Transportation "" ^" www:dat.wisevnsFn,gtiv % \ T355 6l2003 diVtS10N OF MOTOR VEHtCI.ES //��jl//P!1ltt1'+�� File; 791221 F2136 ��, ��,�� RESEARCH 8�MFORMA710tV PO BOX 8070 MADISON Wt 53708-807Q ALE.Y F{NANCIAL Make check payable ta: JACQUE'TTA WALKER �(31gT�q'�1piV FEE TRUS7 'f q946 MCCORNICK RD COGKEYSVILlE MD 21U30 RE: 2004 GMG 1D#- 'IGKESI2S$46178517 Enclosed is the vehicie recard inform�tion you requested. The fee for the vehtcle record in#ormation you requested is tess ihan the amount you paid. You wiN rece�ve a refund af $6.T5 in approximaiely one month. Imag�s are retaaned tor 5 years from th�date scanned and are availabie back tt�0'E-30-2048. The earl�est ti#le record for the 2004 GMC is�ated Q5-26-2Q04, Images for this title number have been purged Please prov�de a dayt►me phane�umber for questions regarding yaur application: (,_,,_,_} If you F�ave any questiorts, call{�i08}266-1466.Tefephones are answered between'3':3�AM and 4:30 PM. Thank yau: BUFtEAU QF VE`HECLE SERVICES � �-1 - �l �� c��'� r , 1 ` - �'�G��S�� : ,� '� Wisconsin �epartment af Transportation � ro � www.dot wrscons�n gov a � Q L?rv�sion of Motar Veh�ctes � � ri802 Sheboygan Ave. �'��o��' Mad�,WI 53747 Thi�vehicle record was created on 01-30-2014 at 08:4fl:'{3�1M.The m€armation is curn+ni as ai this date and t�me. Yehicte Detaiis The vehicie is a madel year ZQ(34 GMC ENVOY XUV VtN: 1 GKES12S9A6178517.The most recent cator on fite is RED. ft is kept i�the City of OAK GREEK in the counry o#MILWAUKEE.WisDOT st�ows tfie tn�ck currenfly has a VAI.ID staius. dther veh3cle details. Fuel Type:Gas StyEe:SP�RTUTiLITY Gross Weight Rating:6,OU1 - 10,000 {3d�meter Detai{s The[ast odometer reading on file is 5 Mt recarded on 05-25-2004,this was an actuai reading. Titte�etails The TitE�:limage number is 44147KTD058.The appilc�tibn was received on 4�-26-2044 and was proc8ssed on 05-2f- 2004.This titie is the current titue for this vehicte in Wiseansin,(Please note tfi�at it is po:�sibie that the vehicle was tided in another siate and that state has not yet reparted the Wiscansin title as cance!led.) Custcrners N�� Role Address VENNEMANN TEMOTHY A Primary Owner ��O�A��E�AVE SAMNT FRAN(�IS,WI 53235 Liens Secured Pa Detail� A�.LY�INANCIAL Activity:LtSTED PO BCIX:8123 list Qate:Q5-26-2004 C4CKEYSVILLE M�21430-8123 R�gl�#C1tl4D D_8'�1iIS - The regisiration is for registration type AUT,ficense plate type AUT,plate number 292GLE.The Regisfration/image number is R017dT5460016.f2egistration et9gible for reriewal,the RRN number is 9T254984221.7he application for registration was rece+ved on 06-23-2010 and is currrerttly effective from 06-01-2010 until 05-31-2011.The product has an operation date of 06-01-201U.The registratian status is VALID. Customers Nssr�e Rale Address � VENNEMANN'TIMOTHY A Primary Owner 4109 5 TRt�Y AVE 5A1NT FRANt;IS.WI 53�35 MILWAUKEE inspection Maintenance E}etails Veh�Cle is subject to IM Testing.