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Klein, Lia�. f NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota �� 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 municipaliry within I80 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�- Middle Initial�Last Name��°-�✓� Company or Business Name C�� Q Are You an Insurance Company? Yes/ If Yes, Claim Number? 'lv� C 1� Street Address Jr 3 �- �2. �v'� City �nJV1�f[� p_ct;r �K� State �� Zip Code �� ' Daytime Phone (�9J� )�_�Cell Phone ( ) - Evening Telephone�)�- a-7� � Date of AccidenU Injury or Date Discovered (�/y � Time_�:�am/� i 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 dama es. S � � Or� � d 35 1� rd st� � ' fee e I " fio a � o a( �' �' � o�e o h� �..�I�ee\ - ` ? � s� '� .� e e� elp- � $c Ot- er C0. J�'1�_v_ba�cl �•��..,K �ov�c Pr ine� n�d; �Sn��"stt' -r k� r�nr� t��n s �rn Ir��( C�v�d<'��o+� . `-rG�� -�� r,� w�S �P�,-rPd a�nd -r(�e -t�re rJn S s1o��(c�sr �.,� a�� -4- �`rD Ve- �1 ow�P �)�AP�('2 't�,tE 't i(P�1 P.�'F '��G�'� Please check the box(es)that most closely represent the�eason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow �My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed � I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim you need to include copies of all applicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. {$I 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 �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 Unknown (circle) Provide their names, addresses and telephon umbers: .-J C�o►^ k FG VI c�c.� -�(�te WtQti,S V1C(Ut�e . J- �(L � r�leS cit �f 51� D�terLaK� oct � � �te �r`Tnc.��s1�i�o. 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 possible. If neces ary, attach a diagram. �1� `f�tel[,�(�l�( k.b�S ��,��L7ed d� • er Lc�ke . 5o�-tt. nF t ,+a(�e�r 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. -�' 3 . �'PtDUn We�t�C" -b rte� � �o^t c� 4 !� �'e o� e o f a �►d �� -r(, o v►i��. Vehicle Claims-please complete this section ❑ check box if this section does not annlv Your Vehicle: Year o�0O3 Make�or� Model License Plate Number State Color �'doe 4 ��tn Registered Owner J o I l K(e i✓1 Driver of Vehicle L-� � Area Damaged f i v►'� City Vehicle: Year ake Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniurv Claims-please complete this secNon �ck box if this section does not apnly 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 attac'ng more pages to this claim form. Number of additional pages� ��C�v�� I✓1 V'a�� -L 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 � Print the Name of the Person who Completed this F rm: / Q- �e i _ � , Signature of Person Making the Claim: i Revised February 2011 �� , � ..,,,r,�,�. � I u�uuK ��MO�� , � INNESOTA WHOLESALE,TIRE,WHEELS & REPAIR S M 3955 HIGHWAY 61 CUSrOMER�pp� WHITE BEAR LAKE, MN 55110 (651)426-4518 SAFTEY INSPECTION ARE REGIU�RED ON ALL VEHICLE page 1 611012014 �•-�� 'M Invoice#46685 pay Phone : 952-516-3734 KLEIN, DAVE Odometer In : � ehicle : 2003 Ford Focus 2.0 L 122 CID L4 SOHC pdometer Out: 0 v :611012014 1:45:26 PM Created Complete : 6110120141:48:34 PM Invoiced :611012014 1:48:34 PM Price Condition Unit Price � Srv Writer:7M -- g�6o.o0 $�so.00 Parts Reference Description $20.00 Q�y cod�e_ _�— $20.00 ALY03530U20N NE FW OCUS 16"WHEEL $0.00 1 - LIFE ROT,FLAT REPAIR,BAL,RD $�80.00 1 -- P2 ........................................... Labor .................................... $0.00 .................. Parts ....................................................... $1.00 SubletlMisc. ............................. ............ $0.00 Su IiesIEPA •• • �� Shop PP ................................................ • • $12.90 Charges Tax @$181.00"7.1250% �1� Sales Tax VISA$1g3•90 Paid ech erti i� CAM with the necessary material and authorize the repair work herein set forth to be done along �o ees permission to r loss or damage to vehicle or articl oureempV y icle in case of ire, I hereby onsible fo rant you and/or y ur ose of testing andlor agree that you are not resp ond your control. I hereby g theft or any other cause bey hWays or elsewhere for the p P hig ed on above vehicle to secure the , acknowledg leted W�LL INCUR A operate the vehicle herei arae ekeepe�s I en s hereby Inspection. An express g 9 On Repairs. r re airs thereto. All Vehicles left over 48 hrs. after repairs are com amount o P S� 4.00 PER DAY STORAGE FEE. 12 Month or 12,000 Mile Warran Customer Signature IMPORTANT !!!! 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