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Adan, MohamudNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that “ …every person…who claims damages from any municipality…shall cause to be presented to the governing body of the municipality 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 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 ______________________ Middle Initial ____ Last Name ________________________________ Company or Business Name ___________________________________________________________________ Are You an Insurance Company? Yes / No If Yes, Claim Number? __________________________________ Street Address ______________________________________________________________________________ City ______________________________________ State _____________________ Zip Code __________ Daytime Phone (____)____-______ Cell Phone (____)____-______ Evening Telephone (____)____-______ Date of Accident/ Injury or Date Discovered _______________________ Time _________ am / 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. ___________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 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 ______________________________________________ ! 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. " 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 " Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt " 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 " 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 55104 Mohamud M Mudezz10 2:30 am 651 651 Selby Ave 12/11/21 5066 Saint Paul 231 Yes They damage my car while toying my car and i have a pictures too so i want to take responsibility of the actions Mn Adan 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 telephone numbers: ________________________________________________ _____________________________________________________________________________________________ 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 as possible. If necessary, attach a diagram. _______________________ ______________________________________________________________________________________________ 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. ______________________________________________________________________________ ______________________________________________________________________________________________ Vehicle Claims – please complete this section ________ ! check box if this section does not apply 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______________________________________________________________ Injury Claims – please complete this section ________ ! check box if this section does not apply 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 ____. 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: ______________________________________________ Signature of Person Making the Claim: _____________________________________________________________ Revised February 2011 11/2021 2014 651 Selby Ave MN Mohamud Adan 12/11/21 Mohamud Adan Mohamud Adan Chevy Gold/tan 1000$ 12/ 5510345 empire Dr,saint paul,Mn, GSH 282 2014 3/4 The front area bumber area and lighte Chevy Or let the city ﬁx the car Mohamud mohamed adan The front the carbumber area and lighte GHS 282 Mohamud Adan Impala Impala