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Johnson, Kyle .� REC�I\J�� NOTICE OF CLAIM FORM to the City of Saint Paul, Minne��1 2014 Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause t0.�qpres�nt����K governing body of the municipaliry 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 wilt 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 OTH R DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD 310 CI�Y HALL SAINT PAUL MN 55102 � � � First Name ��/�� Middle Initial Last Name .�(/h hScl�, —T Company or Business Name ._ _ -; Are You an Insurance Company? Yes/ 1� If Yes,Claim Number? Street Address �� 9 � �'/�q�lP_,v2.�CJ D�� �v-L City ��_��c� l State �l � Zip Code .S s!r/� Daytime Phone((asl) a�� a9s�Ce11 Phone(_) - Evening Telephone(6Sl )�- ISS� Date of Accident/Injury or Date Discovered � ��-I— f�( Time 3 .'�f G am/� Please state, in detail,what occurred(happened),and why you axe submitting a claim.Please indicate why or how y��� feel the City of Saint Paul or its employees are involved and/or respon�,ible for our damages. r �t a� � . Z L CG'-S � ct, .¢ - r � ,` v� r n ; � . Co C�'�� , i n — . Please check the box(es)that most closely represent the reason 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 pro�eriy �Other type of property damage—please specify .5 C 1l`e 2� � 71 U? y ��c� � L Q S T W � n�O �v ❑ Other type of injury—please specify In order to process your claim vou need to include copies of all aunlicable 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 WII.,L NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O 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 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 �a�� �. 7/27/2014 3:29:05 PM LABOR - wrtinrnd r1s� - - . Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-please complete this section circle Were there witnesses to the incident? es No Unknown ( � ) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? es No Unknown (circle) If yes,what department or agency? Sf �z�1 I�G���c� Case#or report# � 4 - !So �l�� 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 as possible. If necessary, attach a diagram. (c3,�► I �n�c �✓c�d. �'.c S . , �V SSl� 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. ��r.� �� � Vehiele Cl�ims �lease com PtP this section �check box if this section does not annlv Your Vehicle: Year Make � Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'u Claims- lease com lete this section , check box if this section does not a 1 How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) (provide date(s)) When did you receive treatment? Name of Medical Provider(s): Telephone Address No Did you miss work as a result of your injury? �'eS (provide date(s)) When did you miss work? Name of your Employer: Telephone Address ❑ Check 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 �� � �- �``� Print the Name of the Person who Completed this Form: k. l G Sv .� ��' Signature of Person Making the Claim: � �- Revised February 2011 Hamline Hardware Hank 755 North Snelling Avenue 851-646-4040 WELCOME TO HAMLINE HARDWARE HANK ! Jan G. 7/27/2014 3:29:05 PM LABOR - WINDOW REPAIR WR 15.00 WINDOW SCREEN SCREEN 2.98 SUBTOTAL 17.98 SALES TAX1 0.23 TOTAL PURCHASE 18.21 Credit Card 18.21 CHANGE O _00 7RAN# 5142 STR# 001 REu# 2 ALL RETURNS MUST NAVE A RECEIPT AND BE WITHIN 30 DAYS OF THE ORIGINAL PURCHASE DATE THANK YOU !