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Fetterman, James ����1 4� �� �UL w 8 2(�1� NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�t� CLE�K Minnr.c�,m.Slnl��.Sln�u�e 466.05.�inte.c�hru "...e��er�•per.cnn...K•hn clriim.c dnma,qe.s frum nn1•municipnlitr....chn11 cai�.ce�ro be prr•.�r•nnvf ln thr ��n����rnin�bncl�'n/�Ihc•nn[nit•ipnlit�'�a�ilhin I80 du��.c n%lerlhr nHr,�rrd lnss nr injiul�i.s discnt�ered a nolice.ctnlin,4!he tinrr.��ln[r.anc! � circnm.�vnnc��.c th��re�o/:and the mm�un<<�/'compensation or��the�r reli�r`d��mnnded.., Please complete this form in its entirety by clearly typing or printin�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. Yuu will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature uf your claim. This form must be signed,and both paKes 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 ' � _L �C-� i 7 r��,��i���-� I�irst Na�nc �J��/��'� � Middlc Initial Last Name Company c�r t3usincss Namc Arc Yc�u an Insw-ancc Company? Ycs/ o If Ycs, Claim Numbcr'? Sh�cct Address J i F� ' �S°'� `�'�t-- ��- � � State ��'t,�'r 'Lip Code �`� /� G- City 4��_ r•- � �S�_ 3•�)J' �,venin 'I'cic honc (�'��) �s`/- 3��-� l�aytimc Nhonc (��I )� 1S-�'�_.Ccll Yhone(�.) g P � -�y- �� � �-� l�atc of Accidcnt/ [njury or Datc Uiscovcred �o "Cimc � am/� Plcasc statc, in dctail, what occui7ed(happcncd), and why you are submitting a claim. Plcasc indicatc why oc how you fccl thc City of Saint Paul or its employees are involved and/or responsible for your damagcs. Sr q + � � >>� � �� —r� T � 1' Nlca�c chcck thc box(es)that most closcly rcprescnt thc rcason for cotnplcting this fortl�: ❑ My vchicic was damagcd in an �ccidcnt ❑ My vchicic was damagcd during a tow ❑ My vchicic was da��lagcd by a potholc oc conditic>n c>f thc strccr ❑ My vchicic was damagcd by a plc>w ❑ I was in urcd on City property ❑ My vchicic was wrongfiully towed anci/or tickctcd 1 _ �Othcr typc of property damage—plcasc spccify Si L A�I1�1( f1��D �c�C �'t�����r��� i la i)���� ❑ O[hcr typc of injury—plcasc specify In ordcr to proccss your claim vou need to include copies of all applicable documents. I"(>I'thC CIB�IIIti [y�Cti IIStC(�I�CIOW, plcasc bc surc to includc thc documcnts indicated or it will dclay thc handling ofi vour claim. Dc>cumcnts WILL NOT he rcturned and t�ccomc thc property of thc City. You arc cncouragcd to kccp a cupy f��r yoursclf hefore submitting your claim fornl. O Nroperty damage claims to a vchicle: two estimatcs for the repairs to your vehicle if thc damage exceeds 5500.00; or thc actual bills and/or reccipts for thc rcpairs p "I'owing claims: Icgiblc copics of any tickct issucd and a copy of thc impound lot rcccipt �'Other property damage claims: two repair estimates if the damage exceeds �500.00; or the actual bills �u�d/oc rcccipts for thc rcpairs;dctailcd list uf damagcd itcros O Injury claims: mcdical bills, ceccipts �Nhotogra�hs arc always wcicomc to documcnt and support your claim but will not hc rcturncd. Pa�e 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pa�es will result in delay in the handling of your claim. All Claims— alease complete this section � Wcrc thcrc witncsscs t��thc incidcnt`? ��'" No Unknown (circic) Pn>vicic thcir na�ncs, addresscs and tcic�honc numbcrs: �C" t �i 11N[ 1-/["D (�C�C �.��iCl�� T/-) � ��' r�, Wcrc thc �olicc c>r law cnforccmcnt callcd'? Ycs � Unlcnown (circic) If ycs, wh��c �i����-c�„��,t��►-����,�y'? Case#or rcport# Where dicl the accident��r injury take place? Provide strcet address,cross street, intersection, name of park or facility, cluscst landmark, ctc. Ylcasc bc as dctailcd as possiblc. [f ncccssary, attach a diagram. S[Z= �-/71=�C ��[-v ��rC fl Iti�L►l �Tl�lE.% Plcasc indicatc thc anx>unt you are sccking in compcnsati<m or what you would likc thc City to do to resolvc this claim tu yc�ur�atitifacticm. >F`� 4 (71� N�� i)�`c �•�� � l- �� i� 77"c'rv Vehicle Claims please complete this section [B'check box if this section doc� not apn_I� Yuur Vchicic: Y"car Makc Mociel Liccnsc Platc Numbcr Statc Col�>r Rcgistcrcd Owncr L�rivcr��f Vchicic Arca Damagcd City Vchielc: Ycar Makc Model Liccnsc Ylate Number State Color Urivcr of Vchicic (City Employcc's Namc) Arca Damagcd Iniurv Claims—please complete this section L�check bux if this scction docs nut applv Huw wcrc yc�u injurcd'? What part(s) uf your body wcrc injurcd'? Havc y��u �c>ught mcdical trcatmcnt'? Ycs No Planning to Scck Trcatmcnt(circic) Wha� did you rcccivc tccatmcnt? (providc datc(s)) Namc of Mcdica! Providcr(s): Address "I'cicphc»�c l)id }���u miss work as a result ofi your injury? Ycs No Whcn did y��u miss work`? (providc datc(s)) Namc of your Empl�>yci° Ad�lress "I'clephonc � � �i,�f�:� [H'Check here if you are attaching more pages to this claim form. Number of additional pages L3y srg�ii�ib this form,you are stating that all informatiofz yuu have provrded is true a�:d correct to the best �ryoier knowledge. Ufisigfzed.forms will rzot be processed. Suhrnitti�ig a.false claim cafz result in prosecution. Uate form was completed ����'�T Print the Name of the Person who Complete this Form: �������� 5 +T't -�K/�/hl�i� Si�nature of Person Makin�the Claim• � � Rc�isccl Fchruary ?01 I / Claim Back�round and Propertv Damage Description On or about Junc �. 201�. a complaint�t�as madc on thc city�s «�cb sitc�1_E����_,sl�?�zEtt�s��±�st��€�,i:���?? rcgarding a damagcd trcc in thc boulcvard in front of 735 Wilson Avenuc. In that complaint, it«�as statcd that a largc branch from tllat trcc had already fallen onto the street and that the remaining branch still attachcd to thc trcc nccdcd to bc cut back to thc trunk to prcvcnt damagc to property or injur��to passcrsb�. On or about June 9. 2(114,citr ��orkers removed a substantial portion ofthe broken branch and trimmcd othcr branchcs on thc trcc. On Junc 1�4. 2U I�4 at approximatcly 2:30 p.m., a windstorm s�•ept through thc St. Paul arca. A largc branch from thc samc trcc locatcd in thc boulcvard in front of 73� Wilson Avcnuc brokc off and landcd on m� front porch stairs causing substantial damage. .At approximatcly 3:00 p.m. that samc da�. a call ��as madc to thc Forestr�� Division of the cit_v asking that the branch be removed. Thc cit�� cmplo��cc ��ho ans��crcd thc phonc said thc� would"look at it". On Sunda��, June I5, 2014, city crcws arrivcd and rcmovcd thc brokcn trcc branch from m�� propert��. Thc Cit� of St. Paul is responsible for thc damages to my property because the city workers «ho trimmcd thc cit� o��ncd trcc on or around Junc 9, 2014 knew or should have known that additional branchcs on tllc trcc ��crc rottcd or��cakcncd and ncgiccted to idcntify and removc them. Witnesses to the incident Thc follo��ing individuals �vcre present whcn the trec branch fell onto the front stairs. Dianc Lcc ;56� 126`�' Strcct Wcst Applc Vallc�. MN ;i 12�3 �,iZ-�x�t-��;x Wcslc� Wright � 1;�0 Wcstcrn A�c N #4 St. Paul. MN ��117 bi I-�0O-4�03 Claim Amount Thc amount claimcd against thc Cit}�of St. Paul for damagcs to thc property is $70�.00. "['his amount is actual damagcs paid to a contractor to rcturn thc property to its prc-damagcd condition. A co��'of thc in�oicc is attach�d. Additional Documentation T��o photographs of thc damagc arc cnclosed. Additional photos and vidco documcntation arc availablc upon rcqucst. - I :>.��:}tii+n4:j::•,:•,::it>.:<�'i'{4:�'�.' __........... ........�..,.,... `C;;�k{�q: .. w....... ........,::.:...................�`.r3�.:`.•:5•:p . .......................... ..... _.........__..._ gg � � %��dv ..�. �w9 �� ��� 3 ���� .�,����� `.'` ���t'��,�`3��"�..�,,��S <" ����,.���a� �i�'1;;�G1� �'�g� '� :�ean ���a�at;,•�, �?� �I��ner Fe�:�r�-r��n 5#1�'� ;3f `J��:l�c�n yv�. ;�t. �'at<1, �.1��f. . `.�'�'�7"�'�6�,E1��: � i`Y�_:i��EY f'p�?i;t; i-'[`tf�;�!"�SrHfF(J E�'i.a�`;��'Ny"�?r��f?t'�Pnv�J��::!',�l`-! i`'!?LL.�rb7 r'�!it�i..i'�i;eiL�e:i j�)':i'�"; llifi i�<'�S'Jri:.v; -0 �-�x.t� 1�?' �;S;�trt���a� S�S �h''.l�;�l � "1••�:ft`�, 1u' L`.'4;��Yr C:�;�df S�� �1�2 �� � t-�x� 1i.i' �.,1:�:��:. f.'�� ��edar �9:'£>.#;`•."� '� :�;i"F'�lr:. 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