Souriyavong, Maniphone Jul, 1, 2014 2: 32PM HP WOODBURV LAB ���'�'��� No. 0517 P. 2 I
JUL 01 2014
NOT�CE OF CLArM FO�tM to t��t�e:�i�nt Pan1, lVUnnesota
Minnesora Stat�5tatute 466.05 states that"...every person..,who claines damages from arry mu�ricipaliry...shall cause to be presented to the
governing body of the r►cunicipaliry within 180 days a�4er the alleged loss or injury is discovered a notics stating the time,place,and
circumsrances thereof,ond iha amounr nf compensation or other relief demanded"
Please complete this form in its entirety by clesrly typing or printing your answer to each question. If more space is
needed,attacL additional sbeets. please note that you wi�l eot be contacted by telephone to clarify snswers,so provide ss
much information as necessary to ezplain yonr claim,and the amount of compensation beiug requested. You will receive a
written ac1.-nowledgement once your form is receirvad. The process can take np to ten weei:s or longer depepdiug on tbe
,uature of your c1a�m..This form nnust be signed,and botb�pages completed. If sometbing does not apply,write`N/A'.
SENA COMPLETED FORM A.ND 4THER DOCUMENTS TO: CYTY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HAI.L, SAINT PAUI,,MN 55102
First Name ✓"l d�lll�l( V1411�/ Middle Initial Last Name �l S U f 1 ll�1 �D h
—� /�/ �
Company or]3usiness Name. . .- -- - �" - .
Are You an Insurance Compam�y? Yes/,� If Yes,Claim Number?
Street Address � l;D✓� G� s �
City � State /�� Zip Code �s� d
Daytime Phone ��C�ll Phone �tJr �i vening Telephone���� e'��
Date of Accidend Injury or Date Discovezed '�'7� �`�_"��e� "� pm
Please state,in detail,what occurted(happened),st�d why you are submitting a claiui.Please indicate wh�or how you
feel the City o£Saint Paul r its empl yees are involved and/or responsib}e f your d ages. ��t,�F �i Q.0 P Gl �iU_��
� G� G �� � - � r�� �� u�
V � ' U'�' ,. C tM � , /
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�,�r /h �Q �c.t�yiti .G( �11hF �7 �7 I_ .-0� /�►4.d '�IT Q �a2(� �i ji1�- . �2� C�O� .
lease�hec the b'x(es)that mo closely repre�ent the reason for�omplet�,ng tlus f°rtn'w��aaed durin�a tow
� My vehicle was damaged in an accident � My vebacle o �
� My vehicle was damaged by a pothole or condition of the street � N�y vehicle was_.damaged by a plow
My vehicle was wrondfully to�vved aad/or ticketed � I was injured on City property
Other type of property damage–please specify —^ �� ��
���'��E1�3$J�c�Pac�?=crat`.� /�/� l �Q
In order to process your claim-�ou need to inclnde copies of all aAVlicable ocuments.
For the elaims types listed below,please be sure to include the docttments indicated or it will delay tl�e handling of
your claim. Documents W�LL NOS be retumed and beeome the property of tb,e City- You aze encouraged to keep a
copy for yourself before submitting your claim form. �
�Properiy dama�e claims to a vehicle:two astimates�or the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills aad/or receipts for the ropaazs
o Towing claims: legible copies of any ticket issued and a copy of the impound lot receipf
a pthex ptoperty damage clauns:two repair estvmates if the damage exceeds$500-00;or the actual bills
and/or receipts for the repairs;deta�iled list of dam�ed items
a Tnjury claims:medical bills,receipts
.c�Photographs are always weleome to document and support your claim but will not be returned.
Page 1 of 2–Please complete and retutn both pages of C�aim For�oa
Jul, 1, 2014 2: 32PM HP WOODBURY LAB No. 0517 P. 3
Failnre to comp�ete and retn�n,both pages will result im delay in the Landling of your c�aim.
All Claims,pleage com�lete tb�,s s�tion
�Vere there witnesses to the incident? Yes .1�Td Unknown (circle)-
Provide�eir names,addresses and telephone num.bezs:
Were the police or law enforcement called? Yes � Unlmown (circle)
Tf yes,what depar�ent or agency'? Case#or report#
Where did the accident or injury take place? Provide s�eet address,eross street,imtersection,name of park ox�acility,
closest la�dmark,etc. Please be detai�le as possible. If necessary,attacl�a dia am. 1� �? i' G� i�►1 G L(S(��
�(S� �� � �JG�� • Zt �1' S� • �/I ►� I Y � Y � f
"�oi.�yZdi ��C� � �E �p►1'S � � � ,$C Q�� �G�r S �- �I�. ,,���� _ e
Please m 'ca e tbe am uut you aze ekPaug�c p ahon or w a you ould l�ce th Ci to do to resolve this cl '
to your sahsfaction. �,U� ,� � ��� _ !S� W�� ������N�
1f'I �-'' / � � C� ,�
�S r�s�i�2S�'h/� � fYi c, mQ�e�t', .
ehicle sims— le e com 1 this seeti n eb,eek bvx if this section does not a 1
Xouz Vebacle_ Year [�i.� Make ; . Model d
License Plate Number S� Sta�ey��Color A1r � P
Registercd Owner i • F r C G'� � \ ut.�' � Gi�!/�N,�
Drivez of'Vehi,cle � ' ' r, 1 ',1�7 .� L
Area Damaged r o� �� k S� S� �'.S�'►(.�+��
City Vehicle: Xear 11�ake Mo 1 Ctiil G�UCt�,
1 � License Plate Number State Color
N Dciver of Vehicle(City Employee's Name)
Area Damaged
Tniurv Claims—please com►plete t6is sectio� � ��ti�- ���- � cheek box uf this section does not a�olv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treat�ueut? Yes No Planning to Seek?reatment(circle)
'VV11en did you receive trea�ent? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
vfIIo'Ii lli�you uu�'� wuiic7 - � (PIOVlaO C�&iC(S)J
Name of your Employex:
Address Telephone �
� C6eck hera if you are attaching more pages to this claivau foxua. NnAaber of additional pages
By signing thxS fOrnt,you are statirtg that all information you have provided is true and correct to the best
of your Aticowledge. U�rsi�ed forms will not be processed
5ubmitling a faclse claim care tesult in prosecution Date foinn was completed / �/� �
Pri�t tb�e Naioae o�the Person w6o Completed this Form: l�Gi ' .� D P ��r Q';� �/.�/� �' i�
� '
Sib aature of Person Ma1�ng tb�e Claim: .r,o � J,� � �ot�� �
ltevised Febtu�ry 2011 �