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Griffith ��f NOTICE OF CLAIM F�11+�t� ' e City of Saint Paul, Minnesota Minnesota State Statute 466.OS states that" ...every perf�ttlJ.xfllo`�Ic��mages from any municipality...shall cause to be presented to the governing body of the inunicipality within 180 days after the alle�e s or injury is discovered a notice stating tiie time,place,and circumstances thereof,and��'�i , nsation or other relief demanded." Please complete this form in its entirety by clearly typing or printing your answer to each questiou. If more space is needed,attach additional sheets. Please note that you will not be rnntacted by telephone to clarify answers,so provide as much information as necessary to eaplain your claim,and t6e 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,snd 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 �,� S 5��k Middle Initial � Last Name �r�� Company or Business Name �� Are You an Insurance Company? Yes/�o' If Yes,Claim Number? Street Address ��tS • City S�"- �u�f Staie _Tl�i1 'Ir/ Zip Code .��C)J� Da ime Phone SI 2 �Cell Phone Q;��r yt' (��-�� / �.�3S�'YEvening Telephone�) Date of Accidend Injury or Date Discovered ��c � �.-�/� 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 respiinsibl�for y�damages. S-e� u `�e�,r.t no�c �- ih vo ��-r 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 y,�ct N, �,'.�, /,,, �v�r�.e __ _ ❑ Other type of injury—please specify In order to process your claim vou need to include conies of�ll suulicable 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 aze encouraged to keep a copy for yourself before submitting your claim form. O Properiy 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 properly 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. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay ia the handling of your claim. All Claims—nlease comulete this section Were there wifiesses to the incident? Yes �c1 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. �n d L�r L►O�rS e Please indicate the amount you are seekin in compensation or what you would like the City to do to resolve this claim ' to your satisfaction. �Lf Z(} Vehicle Ctaims—please comutete this section �l check box if this section does not applv Your Vehicle: Yeaz 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 Iniury Claims-please complete this section �check box if this section does not apolv 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 yow 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 knowledg� Unsigned,forms will not be processed Submitting a false claim can result in prosecution. Date form was completed �2/ ��i Print the Name of the Person who Completed t ' Form: �°S S 7�•� �r .�'+�i��2, SignatQre of Person Making the Claim: -�- Revised Februaly 2011 �� , , , � I � ; ! ; ; � � � t ' � + ` ; ! � � ; � � � � I � � f � � I � � � � � � 1 � � � � � � I ! � � n i '-�� I � 'r� � � � �� ' �- _ I � ; � � � ( �` - � f l I t € � � , � ; � � ► � � I � � � I � � � � � — �_w.��.��lN� I � ; � � �.a�.�__.�.�x �o_.w_=__ �..�.�_ � I � � � �� -� � � , { o z ,�` �a` � � � D m w 1 I � y u' a' D� ' `� e ; �c � _ ; �'?C� T�? 6 � � 3 � � ni m r''m � ( �a'} � � � E � :�F � r p ;n � �� I � m� ,� i - :r-D �� j � �� _ (`� �'� ,� • � � �i �� '� r"D °'� � � . I� �- � I ��i � �f � �� ., ' z m � ,' � � i � �„ ( • m z A 1 /' � � ` y �C Y � � �I� � T r� 4 C� ';� �. 4�s �T�"1: I\ � r � : . �a � j '�` (�� , � � � � �-w_. � �� + ,j � i � !� -. �� = s� � � � .Y�;v � �' � � ; � � � ��I � 7 � � � � �z �� '}a ;..� � P � j° •' • ; 6 � ; � � � i� ` � � � � � � � ,, � � � � 1 ; r a .. 1 � � z . n � � � j � 1 I > � � � � �`' ��", i , i� I I� � � � i�}��, � - ( __ x ' �` c �'° �`� �'� �� i� '� � I� � � I ��1' �� .� � ; � � � � �. �•�; � � � .... m.. �� ,�r � ;� � �� _; �. � � I n' (�-� j J i� r � � , � 3 tPa ao � Q ,� � � , �� --� i�" ;� � ;�� .� � � � � � I � ' �i � � _ ' ' '� �• � � � � � �! o � , � m � � � ; � � � 1 ; � � � � � � � I � �j i ' 1i �� ° z i �r t�'?� � It� � � � � { , (� m D t °� � m � � I ��("j� I � �` d� i ! ; ` m� `� Z � � � . { I { � � S C �� i j i�, i7 � ' � � � � ( � m � f � / �1 i � ! j I / f � � �� ( � � i � �; i �� I - + ; � � _� �_ , i ; � � � ,� �p- ; ! I �� ' I I� ; � , � i Z Z ' ' �� °�;� �� 1�, ; � � ' �r� � t � � � � IJy.(/'y ! i � f � ( �I ;r � �f�, � �� 1 it�., I � 1 �� I I �V. � t I I � II � 1 � � ':� 1 � � j ; � � i .y R � m �' ; ' � � y' � � �L � ' � ' � j ` � i i� ' i � � `� t i � i { � I � u,' � � � c �� U ; � j � � 1 j � i I i � I s � � ' i r � -< 1_ i � ? 1 I i � � � I � � i � \� i i � � �� The city replaced our sewer pipes in July. Following that,we had problems with both toilets. Our plumber flushed the lines but could not clean out the debris and had to replace the parts. We have enclosed a copy of the invoice and aze asking for compensation of$420. Thank you. Jessica Crriffith � � �