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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 $256.48 are attached. Reimbursement is respectfully requested. .��� �_, -�y , ,. ,, �� a W , q,T.-: !' 'R j. ; "�1 J q � . ,. � � ,:__ _ ���" __�*' � .. -�_ . f?,� ' -, � " ��� �J � � f � t r F I RST HAN D D�vesvrative Peirrting jr�va�cE TONY KUKICH ?;21aeF�r:.en�c �i Na.l' '.''; 11�� .F� , X�$^��� Rlch�rA t]�:n�;t:n&hlori��lo���el f�al�9{]:799T r�'•� :t�:�• � ��41`sL�14 I�7 r,L�lMOI�d l�vC . �:�in.P�tui.MN 551{�•i�-:Ei:tv -;`�-�4. . � :�•��'� �z�`?�'1! � -. _. . � i-::z�:'•IF-1�_�!J "�h•1�:�,r.;h1" � _ ; � Broken x��itid���w�;l bidv�f hause . Re�nov�brCUen g:r�: ' . neeAyll r;:���i�55 ; • �'hltejs�+iid 21;3.U0 � � i YO7AL 21,3 UO s THr�NK YOU FQR SHOPPING AT *** DUPLICATE RECEIPT *** FRATTALLONE'S/GRAND ACE Ti-!ANK YO'! ��� �HOFP:�JG ??� 15?� aRnND t�VE F��;?i�����;:�'�/GR�!�i� �;�e dT. rk��� MPd 551�, 1�,`'c ���N� k4'r �'�E !��!F,i��� 1425�t`f �T. P��a� tfN 5510� r��?. 2$8-59$1 u��� �;;�t���� 1425���; (ESi; ���-598i °l��,>"" 3:�)�r`�! 't�R�l �'v �t��� ---------------------------------------- 08/31/14 1 ;24PM 1095G 675 SALE 4AJLA 1 EA 1 ,88 E� N �------------ -------------------�------- t�JINDC�Ii xNG SCRcEN Lr;BOR TAXA 1 .88 DEP ' tk 10.00 EA N 41JSU 1 EA 5,55 EA DEPOSIT �i�.pp 41JINCOi�,� REFNIR SUPPLIES 5.55 DEP 1 Er� 1 G,00 EA N U�LA 1 EA 1 ,88 EA N DEFOSIT 10.00 UlINDO��J �;ND SCREEh� LABGR TAXA 1 .88 F1JGL 1 EA 9.17 EA SUB-TOTHL: 20,00 TAX: 4AlIND04'; REPA?R GLAS� 9,17 TOTAL; 20,00 l�lSU 1 EA 3.60 Ek . CASH TEND; 20,�0 UJINDOI�i REPkIR SUPPLiES 3.60 (��������������������������������� SUB-TQTAL: 22.08 ?AX: 1 .40 TOTAL: 23.4$ � _=» JRNI #C490C4/P «_= BC t�t�T; 23.48 cusT # *�� *** DUNLICATE RECEIPT *�� BK CARD#; ;�XXXXXXXXXXX9470 1D; 8460245G8885 More g;eat deals on T<<titter- keyt=�ord AUTH; 005848 AMT. 23.48 "FRATiA�LONES" or text "ACE" to 91011 Host referer.ce #:253156 Bat# Sl�lIPED Like us on Facebook at CHRD TvFE:�l?Sw EXPR; XXXX Frat±a i lone's .�;ce Hard��lare! Trace # 277CC2 Bank card 23.48 I i illlllllllll IIII II!IIIIIIIIII __» JRNL#C�3156,iP «__ CUST # *37922 ACE REr�lARDS ID # 1919213369 . a��;�_.,,.�----- Name : X___ __ I agree to pay above total amount according �o card issuer agreement (merchant a�reement if credit voucher} Acct: RICHkRD VAN CEJSEN More great deals on T<<�itter- key44ord "FRATTkLLONES" or text "ACE" to 91011 Customer Copy Like us on Facebook at Frattallone's Ace Nardware! ��� � ��� �+ a.�,.°+...A��..� �c..,- ��� =� ���'# 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. M oi "i a � � '�. o °o i N � '"1e C\ � r N �` R y � ° ` F- � � �, � � � �• J i � "' w ar o� ;� LL U O p O CO � � � - � � � (�D O � � � p � 'c�,a, (� � � � c-- z (� ` ! � E}3 Ef3 EiJ' (fj E!� E9' EFT ''� i9 � ..t '_i,� Q � � w [� .. � .� .-.a _1 N aj `,� �� -+.=i � � � o � � � � L � U L � � � } � T � N N �° � U � � y L '� � W � u; (j a; � �`- �-- U F � � m -- o u _ rn � �� m a ,, .� u1 _ � � o � X � ' - O (� o m f-° cr3 a � c� cn F°- s. 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