Burr NOTICE OF CLAIM FORM to the City of Saint �����inesota
Minnesota State Statute 466.05 states that " ...every person...who claims damages from any municipali��sNdll,�ai�s��be presented to the
goi�erning body of the municipality within /80 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 de,��d.���� ���
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� f Ct,��[U� Middle Initial Last Name ���
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Adciress ��" �,tJ(SFcyLp 7qQ�
City g�(— (7�,,,v� State �� Zip Code 5 �p
Daytime Phone((p51 )��- la I� Cell Phone(� - Evening Telephone(_) -
Date of Accident/Injury or Date Discovered _� —a(o ' l �"�( -a�j 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. T�_ Wc�-t{�
w�ai� hr»t-� �� h�o�fi oF N�inoa h.w��sc �.�c! was rc,p��►�1 ►uwo,o�t�► l-�vo . A ta l�,<<ca�p cF
l tl+� (.o�ltC� in� Fvo�/Y oF w�ti �lri rr�.� wt+a c, �vtnk: l�.�R�a -h-z w�,.rc,r h� ru� I}t �vo��rZVs Lle�.rrr.i
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(T�W4ce.bs wc.ni� u�t'D � t��,��. �IwIL �.� 'fLc. �J�r,t� o� 't1� �/�,.n/ hft- Gtia ii✓St 11z rp��,n i C�- .
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t�,�St- ics�.� rY.cS�rr.A 'Ctic_ sti,..�,� do,.� .
Please check the box(es)that most closely represent the reason for completing this form:
O 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
❑��y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
6�Other type of property damage—please specify (M, k' W p�c�.�1h G� w s �„or (��rGd
❑ Other type of injury—please specify � k �� ��� P�Y,
In order to process your claim vou need to include couies 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. ocuments WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for y urself 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
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O 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
O Injury claims: medical bills, receipts
�O Photographs are always welcome to document and support your claim but will not be returned.
� �jduld; �Ar.� '�l�cN 1��G.t-UrCS LLccr¢G� V�✓�-riG C.4� �O� 'h'c t11'�[_ t f�o7 Ylpn,�, .
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 complete this secNon
Were there witnesses to the incident? Y s No Unknown (circle)
Provide their names, addresses and telephon umbers: ��,n�� 1�vr1� (Q I'd- " a 75 �� 3�1 7
Were the police or law enforcement called? Yes �/��i Unknown (circle)
If yes, what department or agency? �4G�c,'� �/�1q�c✓d,t.p-}- Case#or report# S�o►^t w�ah P�s��+�,�
L1n�4 �'MA�2'�Mef�,ccF�/YGC. 1..12
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. tn� ti.�rv f- p�
1,rC— G�VC.v�� c.�" ,� (�,n��1�� I'lktiKi l'�j (�- 5b��M o�r 'ftiG w<�,.✓ N+4:N brr�K,
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. �k 38� , << ��,u� � d�,N,,,,_�.Tti,����--�_ c�.� z g,�• �Me. Meu�,,.�'�
S��d ..T- w�s luc,►u!� 1'e` c:..r �1ic� n�or Gr-ptoc�c �=i- w�,s co�-�ct �n� ��.s �Jr �t c�Pd,nir z� �v� ,
Vehicle Claims—please complete this secNon ❑ check box if this section does not applv
Your Vehicle: Year a.ou1 Make Crv�sl�,/ Model Town� C��N
License Plate Number y p�2 0� I State cn�N Co1or 5��v�
Registered Owner W�.(,.. �����td i�•-,�oa- 3.�rt.r�
Driver of Vehicle 'atvi�l gv¢,2
Area Damaged (Sv� 'j'R N u..
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section � check box if this section does not applv
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 �I
heck uere if 3�ou are attaching rnore�ages to t�i5 �l�zm farm. Ne�mber 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 � — 3 I � o�Ola—^
Print the Name of the Person who Completed this Form: �+��� TAv�w2 L�vn-2
Signature of Person Making the Claim: ,
Revised February 2011
Quality Auto Repair AUTO REPAIR RECEIPT
273 Westview Drive NAME Taylor Burr
West S Paul, 55118 ADDRESS 77 Langford Park
Phone # 952-292-1643 c�nr,STATE St Paul 55108
� , . , . � . � ,. . .. • ' •• � �
1 H6054 Used Gas Tank $ 125.00 DATE ` ` CUSTOMER'S ORDER N0. WHEN PROMISED
1 G9272 Fuel Filter $ 47.87 1/26/2012 68954 1/28/2012
. YEAR,MAKE,MODEL
2001 Chysler Town and Country Limited
� ` LICENSE`NO :`. ` ODOMETER
4ar021
. . .
. . :
.. . . .. SERIAL. ,N,O.'
VIN:2C8GP64L51R140133
' NIOTOR N0:
Hl?ME PHO�!E# - CELL Rt�O�JE# '.�l1DGET
651-646-0555 651-274-1212
• � • � 1
• � ' � ' $172.87 , � ; � . . �.
� • � � • .:GAGS,G.AS,, 10
Cracked Fuel Tank broken line to Fuel Filter discard 'QTS.AtL:,
and replace with salvaged tank. LB$. GREASE
'TOTaL i�'' 10
.. . � • .
GAS','',,::°:: $ 34.24
`- OIL: :
GREASE :
$ :.34:24
TOTAL`ACCESSOR(�S: $ -
�hrs 90 LABOR O�1LY $... ; . 180.00-
PARTS $: � 172:87:
ACCESSORIES $
GAS,OIL,GREASE $ � ` 34:24
M ISC.
SUBLET REPAIRS
TOTAL $ 387.11�
Included TAX
� . . � • , � ; , ; � •
' AUTHORIZED BY � TOTAL $ 387.11'
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