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Rodriguez, Lokie �FCEIV�� JUh! 1'7 �014 NOTICE OF CLAIM FORM to the City of Saint Paul, Mir��s�t�L�,RK Minnesota State Statute 466.05 states that "...every person...who claims dumuges from any municipality...shall cause to be presented to the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circurrestartces thereof,and the amount of compensation or other reldef demunded." 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 buth pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND O�HER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name LUICI� Middle Initial�Last Name 1�0��1 �v�Z-- Company or Business Name ""�"" Are You an Insurance Company? Yes( io If Yes,Claim Number? Street Address 1 ZZ3 M-d�-/z-(s-�A-�Lc� 5+ City S� �-�'��- State �� Zip Code SS)Ol� Daytime Phone( ) - Cell Phone( 12.) �1�- �D Evening Telephone( ) - Date of Accidend Injury or Date Discovered 4-' �- I 4 Time 10'� am/� 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. I-FCE Pbt.,1Cc 1�e(Z-t 1.�3CGI L1�V�J" �v� SU NfZi r`-�C �JS� �G""r'F� 1a-1C�� `�� N-�t' �C�''�.�J �nt M�/ �.A-uc �g,� � sa -i�t�y [3us� ,'��i Z�c.�� CsP�--� �a e�x�L M`( Pr��-+� i7� c��` �Fr�� A+� ��sa,.�. i �c ,a.�n i-��n� S�v�+-� �cZC�4�v t= C�t,�3 w a2� 'l'�t,qn��'�� o��L �-Aiv 1� -� �� NS LA-�� S�zvl C�/VI E ?aJ/�uCM vl�1�F-i i-}�(sat w 1/1 f� S t�� '�ot� �n� cs�-r� A c��s.�ti� .T- S��X�2� pvi.-c3 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 ��►�1Z.�'� � =3�-�2-+� t�"�-C � Other type of injury-please specify In order to process your claim vou need to include conies 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 �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 No c�o�acri� (circle) Provide their names, addresses and telephone numbers: 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. i Zz3 M�z-c;�z-C—T S� s�P�-u� M A1 5�1 a � 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. ` Vehicle Claims—please complete this section ❑check box if this section does not ap,plv 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 Inlury Claims—nlease comnlete 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 wark? (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 �.-I 2— t 4 Print the Name of the Person who Completed this Form: L�+e-�c � 120��cr�sc�._ Signature of Person Making the Claim: � � Revised February 2011 '�{1��0��Y Pa9e# of pages �1:! 1 OPO UBM 4T0: ' JOB�ME � JOB# f' ' ..",fJ� ..f�� n ss r , os canoN � ! .� ^ � � �-f� �°�f� �:' ' . - .c�u ..-'� ��""? DAT DATE OF � f' ' .�' �� .�,�_.._%l/ J�-~� L� �v .� �'1 �� - � �- � � PH E# � FAx# 1 • - i _ �� % � �� ; ; � , ; � 7.�e hereby submit specfications and estimates for: _ ____--- _ __ _ . __-- _ ___ __ _._. ------- � f�. _ ' _. _.._... ..... — �., _� . � __�?.7 L� "'•�/ / _ _-L�,�I.L� "�'�' _ _ %_�A , ' � _ � ,�� j � �? , /� _ _ ��-.-- —�_l�/"""'`r..:�--1�._.-- , -�.�_:_�{�.._ - - --- ----- -�- / f_._...... �, _ �1�- _� �� -- ��-2��_ l`x�� .��-�-��-� � -- :rl_ � � , - - - — � _ / i �:� %G;<�-^�'� � � _�.�/ [r� �r�-��,�' :G„�2.-r�'ii !�'.-- — ,, . ' , , % �� " v , _ , .� _� .;:� G[.-�'r. �..' - '"r 2-L�..-' �- G� �: — _ - �__.,1 .� _ -- �___ __ ------ -- /�� ..f : , . __— __ __ .� t`_ �� % J� --�� `✓ . .� �___ --- �� ---��-.______ � _�^- � - '' -,_ _ -- _ �, � ��. -- _� ! � � , Z��-�- '�"�'i`. C"�--�..L �7��t��'�� _ �'' � _ � � � __ _ __ — _ _ , ,_,_ �, %' - / __� ��c.. �� J``�----� ` ��__ �__ _ ---_ , -- -- . , ;�' -- � — � �e pr ose hereby to fumish ma�al and labor-complete�',in accordance with the above specifications for the sum of: �_..- ,,:> - $ -�-3-c��- /l�r,t- -�-�'� � >�--ti`��,--, _ Doilars with payments to be made as follows �� '`�y�' �"" �'�"� � �L �. ,' t ,. ,,.� . /' My atteration or deviation from above specifications involving exlra cosTs R2SpBCtfUlly � �,,c_`�� t^-�'�-�� will be executed only upon written order,and will become an extra charge submitted — over and above me estimate. All agreemerds contingent upon strikes, accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if n�t`accepted within days. � I �cce�tance of �ro�o�aY ' , The above prices,specifications and condi�ons are satisfactory and are , hereby accepted. You are authonzed to do the work as specified. _ Payments will be made as outlined above. Signature � Date of Acceptance Signature — � A-NC3819/T-3850 09-11 �'�.. Pride,Professionalism & Partnership BRIAN FICCADENTI WSk..M�T'D��S�o� Police Ojfrcer y�2_2�..�.—�7�l1�. POLICE DEPARTMENT CTI'Y OF SAINT'PAUL �e 367 Grove Street Uoice Mail:65l-266-9000 ezt 71822 � Saint Paul,MN 551 1 brian.ficradenti@cistpaul.mn.us CN# � 0 � If you have que ons regarding your report,call: Saint Paul Police Records Unit (651)266-570(1 � Pride,Professionalism & Partnership JILL E. McRAE Conunander POLICE DEPARTMENT CITY OF SAINT PAUL EASTERN DISTRICf Tel:65l-266-5566 '�D' Fw:651-266-5797 367 Grove Street CeII:651-200-7251 Saint Paul,MN 55101 jill.mcrae@ci.stpau(.mn.us � CrvL��sc'> > S T� �P-�2 C�I.L . � �- Yo� �vC �`� QC��i�o-�-�`�, �C�OT'�� Z �c� j7� �� '- t��Z -39t�- �4-8� 1 �4-�i►� l au �'�— Yev2 P/�ca P i ��n o.�1 J i..�� u�-L.