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Robinson, Scott NOTICE 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 answers to each question. If you have additional documentation you may add those documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may < mailto:cityclerk@ci.stpaul.mn.usemail, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102” Individuals: First Name Theodor__________________ Last Name Robinson ______________________________________ Please Indicate Your Pronouns: She/ Her/Hers ☐ He/Him/His <☒_ They/ Them/Theirs ☐ Company or Business Name: ______________________________________________________________________________ Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File <Number?: _____________________ Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ </ Street Address: ___3343 Pioneer Place_________________________________________________________________ City: ____Stillwater____________ State __MN___________ Zip Code 55082__________________ Daytime/Work Phone _________________651 2610578_____ Cell Phone 651 2610578_______________________ Date of Incident or Date Discovered (Must complete) 9/8/2022Time _3:50PM_____________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. ____City worked backed into me while I was stopped_________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____City driver fully at fault__________________________ Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will need to be provided with your completed form.< Photographs will be accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned.< ☒ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Property damage: please provide two estimates for repairs or actual bill that has been paid. ☐ You were injured during a motor vehicle accident: please provide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury. This section must be completed for all claims. Is there a police report for this incident? YES If yes, please provide the police report case number 22-167092_____ Revised December 2021 If yes, what law enforcement agency responded? _____St Paul Police__________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. _________Intersection of Como Avenue and W Hendon Ave in St Paul_______________ Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. What would you like to see happen to resolve this claim to your satisfaction? _____Send me a check____________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. _______Just me and St Paul Employee_______________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year ____2016 Make Honda ___ Model CRV _____________ Color _Brown__________ License Plate # 5NG724 <State vehicle is registered in MN ________________________ Registered owner of vehicle __Scott and Amy Robinson______ Driver __Theo Robinson (son)_________________ Area(s) damaged ________FRONT______________________ If a City vehicle was involved: License Plate # ________929-733 number 2158_____ Color __White____Ford F250_____ Was there City insignia on the vehicle? YES Driver’s Name </w____Eric D Gomez________________________ Other property damaged: __No_________________________________________________________________________________ For injury claims of any type. What part of your body was injured? No Did you go to the emergency room or urgent care? NO Where? _________________________________________________ Was medical treatment received? NO Where? </______________________________________________________________ First day of medical treatment? _____________ Are you still receiving medical treatment? Yes No Did you miss any work as result of this incident? NO Employer(s) <_______________________________________________ How much time have you missed from work?___________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. See attachments By signing this form, you agree that all information provided is true and correct to the best of your knowledge. Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes. Name of Person completing form: _____Theodor Robinson___________________________________________ < Signature of Person submitting this form: _______________________________________________________________________ Relationship of person signing to Party making the claim: SELF Date document is being signed 9/19/2022 Revised December 2021 See attached for Paid Invoice for cost of damages.