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Gevirtz, Aliza . ��c�ivEo '� JUN 18 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minne ota �IT`Y CLERK Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...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 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��1'1 A Middle Initial�Last Name l��L'v I lr�Z- Company or Business Name "" Are You an Insurance Company? Yes/ io If Yes,Claim Number? Street Address ��'(� � . �1�� P�l,� 1�,(�� �� # 3a�'I City �,�►irv�'DJ� � State 1(�N Zip Code�� Daytime Phone 7�)� 3471Ce11 Phone(�Q�)�f��Evening Telephone(��� t2- ��"� � `3a� am/�m Date of Accident/Injury or Date Discovered .1�'.CQ��r(' 1� Time 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 ' are involved and/or responsible for your damages. � nwnp� 0. h aw►�e l W C, � i �I� . 1 ^ t . Sfi � t S 1 ' r ri �- AV i^!h �r tt�v o� fi� w r l�y c o � v � , ' dw �('�ILQ e.s�d i h�s, � �yNa�-Ict' � � Cbv l , U t' 1 h ' h�CbY�i-�nUe t v�vJe'�t'. �v���� Please check the box(es)that ost close y represent the re son for completing this form: mu �,�r S�,{(-�y� ❑ My vehicle was damaged in an accident � My vehicle was damaged during a'to� �� /�y vehicle was damaged by a pothole or condition f�the street ❑ My vehicle was damaged by a ploww�s'` ❑ My vehicle was wrongfully towe and/or ticketed ' ❑ I was injured on City property �CM.b�t D�t� O Other type of property damage—please specify In�15CS • 1 �S ❑Other type of injury—please specify Q�7��C fiD ' � c�hn�ednv��j In order to process your claim you need to include copies of all applicable documents. ,�� �{ �u W►�.h t�'►�i 1 C�Ic� For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of�,j]�� �� your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep���"�� copy fo,�r�y urself before submitting your claim form. � !� Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds�� �s �$500.00; or the actual bills and/or receipts for the repairs i{•�l„�- bi��� O Towing c aims: 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—ulease comnlete this section Were there witnesses to the incident? Yes � nkno (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 facility, closest landmar�fk,�etc. Please be as detailed as possible. If necessary, attach a diagram. W�1'� �JC.Y`f��n"t � N a� �'-4 r JV"�� �.0 � Please indicate the amou t you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �tribsl�. ft7 thc C�St o,� fe��r's '� �y ��ti.� Vehicle Claims— lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year '�1-O�� Make �l Model (s�lo�l�' License Plate Number�I�K.17)� State I'r11� Color W��'C Registered Owner A1�2A �QV�(1Z� Driver of Vehicle " " Area Damaged nw[�r rv�S ; `�G r�v►�t.,�t' U 51�i.-+o.S' City Vehicle: Year Make odel License P e Number State Color 1 � Driver Vehicle(City E loyee's Name) Are amaged Iniurv Claims—please complete this section ��PT' ❑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 �heck 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 ��3i��J� Print the Name of the Person who Completed this rm:!�l Jt� Q `1 C�/!(�-- Signature of Person Making the Claim: Revised February 201 I � , � ° O 14L099�0 '�03af1l�Nl SI a09b1 ON 'h�NO Sl�b'd S�a(l��Nl) `�i�I�ddf1S J.9 Q�NIWa3134 Sd'�adn s��iw aNb SHINOW 'ti3�ldd(1S 13�1ab'V�J�131.�d �Nl 1�8 d�1NtlaabM 3a'd Sll�`dd a�Sfl a0 W�O-NON JNISfI S�il`dd3a ,;sa6ew�p�e;uapi�ui aay�o/(ue ao'awooui ao s�i�oad�o sso�'asn}o sso�ao;sa6ei.uep'�tlaadoad o}sa6ewep `sa6ewep�ei�uanbasuoo�ue�a�aap woa}�anooa�oi pa�li}ua aq�ou��eys�asey�and :sa6ewep�ei�uanbasuo�„sai�u2aasm pagdw� 'S31aOSS���t1 aNtf Sl�ldd N�f1S HlIM NOIl��NNO� NI J.11ll8bll!i0 N011t/Ji180 a3H10 J.Nb ll a0�3Wf1SSd 013NOJ.Nb'S�ZIaOHlfl`d�ION S�Wf1SSb'a3HlI�N dIHSa��tl3a tifl0 oNb' �S31dOSS3��d aNb Sl�lb'd 1N3W3�t/�d3a 3�In�i3S �IflO Ol 318t/�I�ddd J.1NtJat�'dM SS�adX� l.lNO �Hl SI SIHl 'alqe�gdde se `a6ea�iw a�oiyan pue aseyand�o a��p a�epi�en o� 'suoi�e��e�sui aa�eap uo aap�o aiedaa ay;�o�tdo� s,aaseyo�nd ao 'sa�es�a�uno� uo di�s sa�es �eui6uo ay� }o �(doo s,�asey�and ay� y�inn paysivan; aq �snw diysaa�eap �np •�uawa�e�da� ao ai�da.i l�ueaasnn ao� s�noy ae�n6a� 6uunp ssauisnq �o a�e�d s,diysaa�eap ano o� pa�ani�ap aq isnw saiaossa���.io s�aed 6uiuoi��un;�ew ao ani��a�aa �ssauisnq}o aoe�d ano o��4aossa��e�o laed 6wuoi}oun}�8w ay�;o�(aani�ap 6uinno��o;awi� a�qsuoseaa e uiy�inn diys�a�eap�no �tq pawao}�ad aq ��inn/�usaasnn siy�aapun 6ui�(�penb s�uauaaoe�da� ao snedaa �,�a�unoo-ay�-�ano„p�os�Saossao�e ao��ed e�o uoi�e��e�swa�pue e�oiyan ayl woa� �enowa� �o�aoqe� �o :sa6swep �ei�uanbasuo�aay�o ao a�oiyan ay� }o asn Jo sso� 'aoua�uanuo�ui 'awi� �o sso� :penadde�o pau6isap�ou senn i(.iossao�B�o��ed ay�y�iynn�o�asn ao�uapio�e 'uoi�eaa��e 'a�ua6i�Bau wa�6ui��nsaa suo�lipuoo �anoo lou saop��•diysuew�aoM ao�eiaa�ew w s��a;ap o�anp�(asssa�au apsw sluawa�e�daa�o s�iedaa�(�uo saano��(�ueaasnn siyl �/(�ossa���ao�asd 6uiuog�un}�ew ao ani}oa�ap�(ue�o�lasd�uawaoe�daa�ysiu�n� �o aisda�pinn�i `a���yan in������ ��oaaay�uoi�e��e�sui aa�}e 's�n��o�sai�aanay�iynn 'sa�iva 000'Zl �o sy�uow ZG �!4UM(Z)� �+� �d�uawa�s�da�Mau;o a�es aa�}e sy�uoi.0 ZG�o poiaad e ao;(G)�sy�siueaaeM �,UTHER 6ROOKOflLE. 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