Burrows, NicholasNOTICE OF CLAIM FORM to the Gty of Saint Paul, Minnesota
Minnesoto State Stotute 466.05 states thot "...every person...who claims damoges from any municipolity...sholl couse to be presented to the governing body of the
municipolity within 180 doys after the olleged loss or injury is discovered a notice stoting the time, pl.oce, and circumstonces thereof, ond the amount of compensotion
or other relief demonded."
Pleasecompletethisforminitsentiretybyclearlytypingorprintingyouranswerstoeachquestion. lfyouhaveadditionaldocumentation,youmayaddthosedocuments
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) week. This
form must be signed, dated with all applicable sections completed. Submission this completed form to the Saint Paul Citv ClerlCs Office by email
(cityclerk@ci.stpaul.mn.us), fax (65L-266-8574) or mail addressed to "Saint Paul City derlC 15 West Kellogg Blvd., Suite 31q Saint Paul, MN 55102".
Claimant: First Name: 11 i t)1t-'.\ .r;-a Last Name: '.'l'.-. i r ; i -')
Please lndicate Your Pronouns: tr She/Her/Hers, p.He/Him/His, tr They/ Them/Theirs
lfyes,provideyourlnSured,s/Client,sName:
Company or Business Nam-e:
ls this claim being made by an lnsurance Company? YES /NO lf yes, what is your Claim/File Number?
ls this claim being made by an Attorney? YES 71i6 tt yes, what is your File Number?
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srreetAddress: I qu) S'te$OnS $sle t\<t
City state: NJ\il zip coa", 5SHO3
Daytime/Work Phone:"114 Cell Phone - I LlLtg',
Date of lncident or Date Discovered (Must Complete):'l Time ll:15 ar,*.
Please state, in detail, what happened that prompted you to file a Notice of Claim Form:
Please state why or how you feel the City of Saint Paul is responsible for your Damages ? $ *€.-(<A, ob t}dleq
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.
n Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
J&Automob'le damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
E Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from lmpound Lot, and two estimates for repairs or actual bill that has been paid.
E Snow Emergency: please provide copy of towing ticket (if available), receipt from lmpound Lot, and two estimates for repairs or
actual bill that has been paid.
E Property damage: please provide two estimates for repairs or actual bill that has been paid.
n 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
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
Revised March 2023
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Tf;rs l:ction must be liJr!:.' ;-.
ls there a police report for this incident? YES /tf{O
lf yes, please provide the police report\ese number:
lf yes, what law enforcement agency responded?
Where did e incident take place?-Please provide a street address, intersection or name of city park or facility:
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What would you like to see happen to resolve this claim to your satisfaction?
Were there witnesses to thls incident? Please provide names and contact phone numbers
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Your vehicle's information: vear: Z S2\ M3kg; M\rk5\tb!3!f\ Model Color
License Ptate #; tz v-,'K - *i t w State vehicle is registered in b-^ N)
Area(s) damaged
lf a City vehicle was involved, License Plate #:
Was there City insignia on the vehicle? YES / NO Driver's Name
Color:
Other property damaged
For iniurv claims of anv Wpe.
What part of your body was injured?
Did you go to the emergency room or urgent care? YES / NO Where?
Was medical treatment received? YES / 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? YES / NO
Fmnlnrrpr/c\'
How much time have you missed from work?
lf you are submitting other documents, please state what you are attaching and how many pages:\
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:-f,
Signature of Person submitting this form
Relationship of person signing to Party making the claim
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Date document is being signed
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