VanDeusen, Richard ��'4,r��4�Lw�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�i�a�� ����
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to��i�s�t�����'�
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. Yon will receive a
written acknowledgement once your form is received. The process can take up to ten weelcs or longer depending on the
nature of your claim. This form mnst 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 �/��i�/'�f Middle Initial�Last Name 1 �.��GuS�-iv
Company or Business Name
Are You an Insurance Company? Yes/1Vo If Yes,Claim Number?
Street Address l 99 � S�' ,vF"o�� A'�/�
city ,�7`- ���/ state /'-t N Zip Code SSld-S�
Dayrime Phone(_) - Cell Phone(�5��� �4s/3 Evening Telephone( ) -
Date of Accidend Injury or Date Discovered A�-t�I. �-���`' Time /O.'-3��pm
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 damages.
S� R�TTa��
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 property
�Other type of property damage—please specify �•r`�ke.v �i.v��v �v� S�rw� s�sti
❑ Other type of injury—please specify
In order to process your claim`r�u u�ed to include couies of all annlicable 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.
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 esdmates 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 aze 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 comnlete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcernent called? Yes No Unknown (circle)
If yes,what department or agency?Stf�c.�P��� -- re�r� Case#or report# N�o�v`�,`v�
LtS %O Pub/i��trlovlc's M4rvl�L.UG7.l�GB-
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. /%97 St�,v��.-d��a r,e�
�T Pu��N.. 7Zi is is�1+.-�'��'•v�i-Ho.�r� c,�1,UE�or,�.r.- o,�'�'�vFor�� .��.vti��
Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ..,4`z �'6 •�'
Vehicle Claims-please comnlete 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(Ciry Employee's Name)
Area Damaged
Iniurv Claims please complete this section .�'check box if this section does not annlv
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 attaching more pages to this claim form. Number of additional pages .3 .
By signing this fornz,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 s�o� rGr L a��t
Print the Name of the Person who Completed this Form: ���i '/ �� v � � �
_ �`�
Signature of Person Making the Claim: � �'��--_""
Revised February 2011
Fallen limb damage to window at 1997 Stanford Ave, St. Paul, MN 55105
At approximatiy 10:30 AM Sunday, Aug.31, a limb fell from a locust tree on the boulevard immediately west �
of our home located on the corner of Kenneth Street and Stanford Ave. in St. Paul. As it landed, the large '
end of the limb struck a window, penetrating the storm window and the center pane of the upper sash of the
window itself(see attached photos). The force of the blow also damaged the frame of the lower storm sash
of the same window.
We reached St. Paul Public Works Maintenance through calling the Police Department. The Maintenance
person who arrived shortly afterwards surveyed the situation and called the Forestry Dept. Forestry sent a
crew to remove the limb and trim the part of the tree which the limb had broken away from, and which itself
was threatening to fall. A Forestry crew returned on Friday, Sept. 5th to do some additional necessary
trimming of the tree.
The window has been reglazed and the storm sashes have been repaired. The paid invoices for these
repairs totaling $256.48 are attached. Reimbursement is respectfully requested.
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*** DUPLICATE RECEIPT *** FRATTALLONE'S/GRAND ACE
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08/31/14 1 ;24PM 1095G 675 SALE 4AJLA 1 EA 1 ,88 E� N
�------------ -------------------�------- t�JINDC�Ii xNG SCRcEN Lr;BOR TAXA 1 .88
DEP ' tk 10.00 EA N 41JSU 1 EA 5,55 EA
DEPOSIT �i�.pp 41JINCOi�,� REFNIR SUPPLIES 5.55
DEP 1 Er� 1 G,00 EA N U�LA 1 EA 1 ,88 EA N
DEFOSIT 10.00 UlINDO��J �;ND SCREEh� LABGR TAXA 1 .88
F1JGL 1 EA 9.17 EA
SUB-TOTHL: 20,00 TAX: 4AlIND04'; REPA?R GLAS� 9,17
TOTAL; 20,00 l�lSU 1 EA 3.60 Ek .
CASH TEND; 20,�0 UJINDOI�i REPkIR SUPPLiES 3.60
(��������������������������������� SUB-TQTAL: 22.08 ?AX: 1 .40
TOTAL: 23.4$ �
_=» JRNI #C490C4/P «_= BC t�t�T; 23.48
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*** DUNLICATE RECEIPT *�� BK CARD#; ;�XXXXXXXXXXX9470
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CUST # *37922
ACE REr�lARDS ID # 1919213369
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I agree to pay above total amount
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Acct: RICHkRD VAN CEJSEN
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��� =� ���'# 08/25/2014
�I T�Y ����'�`i Jama1 Sa,ida
195 E Congress Street
APT: A St. Paul MN, 55107
Claim
My car was towed and damaged, the driver door was forced and opened I don't know
why they opened it but it was opened. They opened the driver door and tied the seat belt
to the steering wheel, there are scratches on the inside and there are holes on the door
rubber due to the force it was used to open the door; now the door is not closing properly.
Due to the damage on the driver door the air is coming in from the side of the door. Also
there are damages on the back bumper on both side and scratch's on the lower side of the
cax. I want my passenger door to be replaced, scratches to be fixed and my back bumper
to be replaced. I took the car to the shop to get a quote and the door is estimated to cost
$1200 dollar before labor and the back bumper is $600 dollar before labor also the
scratches are estimated to cost $580 before labor.
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