Gaetz � 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 olher 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
�a��� RECEIVED
First Name � q,� Middle Initial Last Name
Cor.ipany or Business Name N1 ��he 5��� ��,�a;��e.��� � �l'�ti��s U��`l.o.tt f��1 ��� I Z Z�12
Are You an Insurance Company? Yes No If Yes, Claim Number? ��, i {�i�K
Street Address �J���J J�=�►� I.f e-��c"�� [� �v;� , N�`� Z � �
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City �fi 1'[,lU� State iY1f V Zip Code .�5�5�
Daytime Phone �( 57 )�- `��'�� Cell Phone(_� - Evening Telephone(_) -
Date of Accident/Injury or Date Discovered ( � � �� � zb(i Time �1 7� 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 yo, damages.
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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
O My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed andlor ticketed � ❑ I was injured on City property
�.Other type of property damage—please specify �"f�.`1��t `�(�i't��� a�d S��t h
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all aqplicable 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.
O 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 owing 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
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 in the handling of your claim.
All Claims—please complete this section
Were there wifiesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Y�s No Unknown (circle),
If yes,what department or agency? +��N `����c Q ft�` Case# or rerort# I 1 `-108 �`}6
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,attacli a dia ram.
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Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
*e your satisfactian. � � ; �Z�, 3 L
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 zD0 i Make S� Model �K
License Plate Number ���-j i� State I�N Color !�,�e.
Driver of Vehicle(City Employee's Name) ���ow�.� �ac'�e I L�t, 2t'
Area Damaged
Injury Claims—please complete this section �heck 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
Di�you miss work as a rssult of your injuri;? Yes '.`;�
Whsn di3 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 know[edge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed � ` 0 ` Z�'� Z
Print the Name of the Person who Completed th' Form: I� 1 a-� ������
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Signature of Person Making the Claim: / t�✓l �-:
Revised February 2011 /�• S �� , /
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Please RemitTo: Q�,��s�
• DEPARTMENTOFTRANSPORTATION � "°���' State of Minnesota
FINANCIAL OPERATION MS 215 �� p"'
� 395 JOHN IRELAND BLVD __.�� INVOICE
ST.PAUL MN 55155-1899 -- -
�'�+ie6$*
Customer No: 0000179182
Payment Terms: Due in 30 gi��To:
Due Date: 4/1/2012
Invoice: 00000062605 SAINT PAUL REGIONAL WATER SERVICES
Invoice Date: 3/2/2012 1900 RICE ST N
From: 11/14/2011 To 11l14/2011 ST PAUL MN 55113
Page: 1 of 2
AMOUNT DUE: 1,727.32 USD
Original
For billing questions,please call: 651-366-4856
Line DescripGon QuantltyUOM Msg UnitAmt NetAmount
1 EQUIPMENT �,pp Eq 18.80 18.80
VAN 20 @ 0.9A/NII=518.80
2 MATERIALS 1.00 � 1,311.77 1,311.77
SIGN POST INSTALLATION 30 @ 12.55/FT�5376.50
KEEP RIGFIT SIGN 1 EA=559.68
CHECK DAMAGED POLE 1 EA=$I61.94
l2"VISOR 1 EA=527.70
PED PUSA BUTTON 1 EA=$530.77
SIGNAL PED BASE 1 EA=S 155.18 ,
3 LA80R �,pp Eq 396.75 396.75
i
HWY SIGNAL TECH 7.5 Q 52.90lHK=$396.75 I
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ACCIDENT: 11/14/11 SIGN&SIGNAI,LIGHT DAMAGES
MN!]0 WEST BOUND AND LEXIIdGTON AVENUE
DRIVER: .IEROME DARREL LUCKE[t
2001 S7'RG TRUCIC PLAT'E#930315 MN
Subtotal: 1,727.32
AMOUNT DUE: 1,727.32 USD
�'
PLEASE REFER THIS INVOICE TO YOUR INSURANCE OR IF SELF INSURED,
REMIT PAYMENT. •
WE DO NOT ACCEPT CREDIT/DEBIT CARDS OR ONLINE PAYMENTS.
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- � °'°+'•� Invoice: 00000062605
�?'���° � ..� State of Minnesota
M.'.� Invoice Date: 3/2/2012
�� .�, INVOICE Page: 2 of 2
�P�''i'+�i�s*�y
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Bill To: Customer No: 0000179182 �
SAINT PAUL REGIONAL WATER SERVICES Payment Terms: 'i Due in 30
1900 RICE ST N Due Date: 4/1/2012
ST PAUL MN 55113
Address Change?If yes,check box. ❑
Write correct address on back. —►
Please Remit To: AMOUNT DUE: 1,727.32 USD
DEPARTMENT OF TRANSPORTATION
FINANCIAL OPERATION MS 215 �
395 JOHN IRELAND BLVD Amount Remitted
� ST.PAUL MN 55155-'i899
�
T79d2 OO�OOO�D0179182 ❑ 0�000062605ZZZZZZZZZZZ 4 0000172732 !