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Wilhite, Gregory
����IV�D NOTIC� Or CLAIM I�'�RM to the City of Saint Paul, Minneso�� 201� h9innr.�n�u SIrNc�Slcltr�te 4(ih.05.�7nle�s Ilrai "...e��Prv pc r.s���r...whn�laim.��dnma,��e.r from n�iv muriiripu(ih�....cltafl rnu.se�T'��e/���e.c�-�r��l�'tl�e� .�u��er-nirrg but(V U�lI7('!IlfIIIICl/)(!II/V N'llll(!I 1�51)d�rvs cr/�ter t/re u!'e,�e(I/n,ss or IliJttYV is c/isc�OVere[I[t i�nlic�e s1a�i�r��t/rc ti�nr,��Ine�e,cuul �ii-runcctunce.r tlreren/; n�id 1l1e umnunt n/�cnntpen.satrn�r or n�{rer rrlic�/�denian�(nd." Please complete[his ti►rm in its entirety by clearly typin�;or printin�;your answer lo euch question. 11'more space is needed,�ttach additional sheets. Please note lh:�t you will not be cont�eted by telephone to clari('y answers,so provide as much information as necessary to explain your claim,and the amount oC compensation bein�;requested. Y��u will receive a writlen acknowled�;ement once your form is received. The process can t�lce up to ten weelcs or lon�;er dependin�;on ihe nature of yuur claim. 1'his 1'orm must be si�nect,and both pa�;es completed. If somelhin�;does not.�pply, write `N/A'. SEND COMPLrT�D I�'ORM AND OTH�R DOCUM�NTS TO: CITY CLI:RK, 15 W�ST KI:LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 Tirst Name t' Miciclle Ini[ial�Last Name�ti�\/�,\� P� ComPany or Rusiness Name � Are Yc�u an Insur�►nce Company? Yes/ o Iti Yes, Claim Number? Stl-eet Ad�lress l� So2. ,`US S �U� � City _� �. 'C'��Jt State � /� Zi� Code � ��� D<<ytime I'hone ( ) - Cell Phone ((�,��)�- J N5�Evening Telephone ( ) - Date of Accident/Injury or Date Discovered �//�� Time l� -0O vn/ m Please state, in detail, what occurred (h�tpPenecl), and why you are submitting a claim. Please indicate why or how yc�u feel the City of Saint Paul or its employees are involved and/or resPonsible for your damages. � prop� �o�'�rr�piS C+i�� (�(� �r i.�J �C ��, 'A �c, w T VSC. �au�l�'i" 1'v� r,,, a � _ � �- er Aw f �1� �J -L'�. r � i,a� L�-�- '� �' f o F � 'Tl.,.rj _ � NI N �L. � V�Y��� �N IS -• � �M L✓ l..e J�Q. O C' �2�/+.J i N ► \ Please check the box(es) that most closely represent the re�ison for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damagecl during a tow G tviy vehicle was elamaged by a Pothc�le or condition of the street ❑ My vehicle was damaged by �i P!ow ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ��O�ther type of Pro�erty damabe—Please specify ��P�l/GP� 'LJ Uther type of injury —please specify ln order to process your claim yoti nced to include eopies oi'all annlicable documents. For the claims types listed below, please be sure to include the documents indicatecl or it will delay the h<<ndling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yc�urself before submitting your claim fonn. O Property damage claims to a vehicle: two estimates for[he repairs to your vehicle if the d�unage exceeds $500.00; or the actual bills and/or receipts for the rePairs O Towing claims: ]egible copies of any ticket issued and a copy of the impound lot receipt O Other�roperty damage claims: two rePair estimates if the damage exceeds $500.00; or the actua( bills and/or receipts for the repairs; detailed list of damaged items O Injury claims: medical bills, receipts O Photographs nre always welcome to document and sup�ort your claim but will not he relurnecl. Page 1 oi'2—I'lease complete and return both pages of Claim rorm I l�ailurc t�► con�plcic and relurn both pagcs will result in dclay in lhc I�andling of your cl�iim. All Claims— plcasc c:ompletc this scction Werc lhcre witnesses to tl�e incident7 Yes No Unknown (circic) Provide th�ir names, <<cldresscs ancl telephone numbers: Were the police or law enforcement called`? Yes No Unknown (circle) If ycs, wl�at dcpartmcnt or agcncy? _ Case#or report# Where did the accident or injury take Place'? Pcovide street acldress,cross �treet, intersection, nail�e uf p�u-k or faci �ty, closest l�inclmark, ele. Please be as c]etailed as possible. If necessary, attach a diagram. ��S�Z RGSSd �-�'�7! _ Pr�r,��/ Please indicatc: the � nount you �-e seeking in comPensati m o�what y u woulcl like the City to clo to resolve this claim to your satisfaction, L�:�;� � �� �C�►�CE 'L Vehicle Claims please comnlete this tiectioki �check box if this secticm elc�es ncx an►�lv Your Vehicle: Year Make Model License Plate Nwnber State Color . Rcgistcrcd Owncr Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Naine) Area Damaged lni��rv Cl��ini5— Plcasc complcic this scctiun kG check box if�this section cic�cs not at�nly How werc you injured'? What part(s) of your bocly were injured? Flave you sought medical trentment? Y�s No Planning to Seek Tre�itment (circle) When did you receive treatment? (provide date(s)) Na�ne of Medical Provider(s): Address Telephone Dic7 you miss work as a resull of your injury? Yes No '�Vhc�� di.� }�ii r►3'tss work? (Pr:3vi,!c dalc(s)� Name oC your Employer: Adclress Telephone � Check here if you are attaching more pa�es to this cl�im furin. Number ol'addilional p<��;es Ity sig��ing this forrn,you are staling diat crll infor�natio�e you leave provided is trr�e ancl correct lu llie liest of your kitowled��e. U�isig�tecl forms will irot be processed. Srcbntitti►ig a fnlse clainz ccui resu[t i�i prosec�ctio�z. llate 1'orm was completed b � � Yrint the Name of the Person who Complet� 's Foriu: ��2C� � �'. �i�;naturc of Ycrson Mukin�; the Claim: � " — ltcvisc� 1�cbruary?01 I IC . t :..:�TL. r�1 f�- .l. ,Y in 7. .;.5 ,. � y�«a��r yi�y >F .s�+1��+Y ��' \M �k �� '�N� r� �����?"y V.�FI`t R�n'*�' A � .!� ♦�T r��� V"� Q f, ���l� � �y�.���f �,�y�'�N ( '�Yw'... �� �P� '. � "" yv� yd i ) �I vr �• � �' �f '����� ��4! � ! .�f1"�� -i-r.�nr�r � �.�1�! ���� �'11i .��1�t' �i� '�J��J���t ,�' �Ar L �*. y/4 �1 � �`r �. � o i a �� �;�. ,,�t ,r� � �M� � ' � (� � ; il y,`1 r 71F G�t.t a(�7'"y �,'•� R �i .� A ..- '�s��' �`1r �I 4� iI r ( I ���� �♦ . -.� lf ��'��fi �� //I � . *�(e .Z^r'4 f R� .,.•.• � `/! - �W'/ '^�• in � �� �n i � l l. �� It�r ��I!/'�y � !ar { �'°a �� �'1 �t AP ��' i � ��� �� � ,� � _ ����M �o' %i"�k t �1�J a I i '�.'9)H � � � • � -r � t ���„ w.-�Il�� 1. .,�� �11'K "*T "S'�r� k� �l�y� �e,�e'�` �^�' � K.i f�,e} „'Yr > � �u '�j r !:r> �`"� �1' �! � J r I � �i [ i i . / I� �1�{� A � -. �{r 'r r. � �� '����1�.�a'►`l S�.f 1��j�� �i,c y J.'Ii �,N�r �p'k�t dtT•A'� �,r �/�/'� ��' l,s�I�' ���`�'r+''f.Y .?,��t,���r�� w✓ >>� .�t�f� r �y�,�_ T'+Gr�'dY" � ��'i��'>� y`wr �a� � � r � � � �,- n<�.A �- �` � ��; 1 Yl c- +�t I�n� f 1�, i��k h P� I0�� o'�R 0^:�r ,,>� t �� . � � i����, t' �l ti.l�..} i i�1#'�,' �� �ti�� . . �nli " �Z'y"I.��� � w+�i. te M�. �"�11v ��f�%'y� � A,r t��,i. fr;�''�,��' a�i'1,�;r'i' ,�'�j��'����`?/��+;,,h,,�,��e"�r• � , � ,�►a r' ��-z s :,�� � � ,.�.,iu ���;. f+"``'Y:�j1z9� .�il► n�`��.'a'..�: a��'a �,.,1�'f�j�'� d ty�r+'Sr'Y�' S �, r .y 1�t - y � �7�° eY ���•t ��"'/� �y) r>� \�, � M,�w .,y ,y��.,n �r�' � D .{'h. . a�.i�' , 1 { .RtMa I/'��, � �: °��h S��'r-'1 • � �,St°Y ,F .. �p ''�.e°:��•, '�G � �Le.� Rr,y° ,.,6M,; '�,,�`tti w.,,, � � t�r/�, cih% c � �kl� �3 ti �' t � ol ♦, �:s'�1��t �� A :i a y ;f � 4 ,�i 19�/a � . w� !4 � �k � �l ,��� .T e' +�j-r i; � .�: s" � `+�' $N d e f� ' � � �; ' ,�'�- {�+:S'S. + rp� v�-^ �"Y'✓ 4 � r �� Ia �f/ �A •� � d �'Q t T ?l A' K-`•r� cS. , p '� ♦ X' J� � 'S�y�.n� � ,d"YR. � v�. .. .a y+�a ,.� / �.�i��a�+1�'�� w `S4� �.. y.sl V1�v�,y ..F� '�`Y C r� R A C n ` '�3 e�., +� .�� ,� 4 . � . k ,c1, t '�1r� f�•� � e v �`�• � � � i rr j, y� , v� � /�.. �iii .4P� � r 4i�(,',� �i � Po:,+.g•.�r .+Q � �1i � �a. t �a' ra � h' �f(r �� r t r S ,p ��r s ! t,i �yat��. �d �'.�.p9 a►1 1r � h , 1 �... 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