Olson, Janet �
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NOTICE OF CLAIM FORM to the City�,�rf�,�aip��'aul, 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 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 ezplain 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 e� Middle Initial�Last Name ����
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address r��`,3 (' U p ip(� �-�-�-g� ��
e
City__������� State �� (� Zip Code ��(p
Daytime Phone (�,O� ,�,�� Cell Phone��----=-� Evening Telephone(�SI )1�/- �S'"a J
Date of Accident/Injury or Date Discovered J �.. � .3 /�, 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 aul or its employees are involved andlor respo sible for your 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 ❑ M vehicle was dama ed durin a tow
Y b $
❑ I��y�a�hicle s�as damaged by a Yo±ho?e er�endition of±he stree± ❑ My vehicl�was dama�e�by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
�Other type of property damage-please specify r ��'tl.
❑ Other type of injury-please specify
In order to process your claim youu need to include copies of all apnlicable 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 encouragec�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 Towing 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 witnesses to the incident? Y e U own (circle)
Provide eir names, ad es and tel ho numbers:
Were the olice or law enforcement called? Yes No' Unlrnown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address, cross stxeet, intersection,nam of park or facility,
closest landmark, etc. Please be as detai d s possible. If necessa attach a di am.
Please indicate the amount ou are seeking in compensation or what you would like the CitX to do to resolve this claim
to your,satisfaction. �—/ - / � � �� T
Vehicle Claim��lease com„plete this section ' ❑ check box if this section does not applv
Your Vehicle: Year 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
Injurv Claims please complete this section ❑ check box if this section does not apply
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
�'�'hen did yau miss work? (prc�vide date(s)j
Name of your Employer:
Address Teiephaire -
�1Check 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 haveprovided 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
Print the Name of the Person who Completed his Form: �1(�(n 7� � / 1 � I s�
Signature of Person Making the Claim:
Revised February 2011 �p� � O��/��,
RUMPCA SERVICES II�VOICe
1048 HASTINGSAVE Invoice No.: 27724
ST PAUL PARK, MN 55071 Invoice Date: 1/19/2012
651�59-2896 Fax: 651-459-0967 Work Date: 1/19/2012
Bill to: Job Address:
JANET OLSON JANET OLSON
1623 UNIT C UPPER AFTON RD 1623 UNIT C UPPER AFTON RD
ST PAUL, MN 55106 ST PAUL, MN 55106
ID: 1623CUPPER Payment Terms: DUE UPON RECEIPT
Contact: JANET OLSON 651-7745255 Reference: Work Order 14252
PO Number:
Item Description Technician Quantity Unit Price Amount
L.abor
SEWER&DRAIN SERVICE AFTON 156.00
CLEARED MAIN SEWER FOUND PLUGGED 60 FEET OUT COULD NOT TELL
WHAT IT WAS PLUGGED WITH
SERVICE CALL
56.00
COUPON -10.00
,
I
WE ACCEPT MASTERNISA/DISCOVER FOR REPAIR SERVICES ONLY Subtotal:
202.00
CREDIT CARD#
Sales Tax:
3 DIGIT CV CODE
Total Due: 202.00
NAME ON CARD Payment/Credits 202.00
EXPIRATION DATE
Balance Due: 0.00
SIGNATURE
ACCOUNTS NOT PAID IN FULL IN 30 DAYS ARE SUBJECT TO A
FINANCE CHARGE OF 1.5°k PER MONTH. MINMAUM FINANCE
CHARGE OF 51.00.(ANNUAL PERCENTAGE RATE OF 18%)
Invoice No.:27724 Thank you for caliing Rumpca Services
�CTIYdc COIIKI'Y �/��/`{
CREDIT(dYION Y
JANET M OLS�N Account Number: �ocxx-xxxx-xxxx�
TRANSACTIONS (Continued)
01/15 O1/15 2438894D09P9MQDR0 MR H COLATE.COM 000-0000000 NY 45.50
01/19 01/19 2464373D4LQFDLFIY UM A SERVI C 651-459-2896 MN 02.00
01/25 25 2461043D903ROZHSL QVC 677117801 800-367-9444 PA 27,g�
Ot/25 01/25 2461043D903ROZH8Q QVC d03675819401 800-367-9444 PA 35.21
Fees
TOTAL FEES FOR THIS PERIOD 0.00
Interest Charged
01/29 01/29 Interest Charge on Purchases 0.00
01/29 O1/29 Interest Charge on Cash Advances 0.00 I
TOTAL INTEREST FOR THIS PERIOD 0.00 �
TOTAL'FINANCE CHARGE' BILLED IN 2011 $225.35 '
2012 Totals Year-to-Date I
Total fees charged in 2012 p.pp
� Tntal intorost r.harnerl in 9(119 n nn
RUMPCA SERVICES I I�VOICe
Invoice No.: 27969
1048 HASTINGS AVE
ST PAUL PARK, MN 55071 Invoice Date: 3/6/2012
651-459-2896 Fax:651-459-0967 Work Date: 3/6/2012
Bill to: Job Address:
JANET OLSON JANET OLSON
1623 UNIT C UPPER AFTON RD 1623 UNIT C UPPER AFTON RD
ST PAUL, MN 55106 ST PAUL, MN 55106
ID: 1623CUPPER Payment Terms: DUE UPON RECEIPT
Contact: JANET OLSON 651-7745255 Reference: Work Order 14519
PO Number:
Item Description Technician Quantity Unit Price Amount
Labor
SEWER&DRAIN SERVICE JASON 156.00
SEWER 8�DRAIN SERVICE LEONARD 0.00
WHEN WE ARRIVED WE RAN CAMERA INTO THE LINE,WENT OUT 50FT AND
FOUND CITY MAIN PLUGGED. RAN CABLE MACHINE INTO THE LINE
CLEARED LINE BETWEEN 50 AND 60 FT RAN OUT TOTAL OF 100FT FROM
CLEANOUTACCESS IN THE HOUSE. RAN CAMERA INTO THE LINE AGAIN
OUT 100FT LINE CLEARAND WORKING WELL.
SERVICE CALL 56.00
. _
_ _ __ _ _ _ — - -
WE ACCEPT MASTERNISAIDISCOVER FOR REPAIR SERVICES ONLY Subtotal: 212.00
CREDIT CARD# Sales Tax:
3 DIGIT CV CODE Total Due: 212.00
NAME ON CARD PaymenUCredits 212.00
EXPIRATION DATE
Balance Due: 0.00
SIGNATURE
ACCOUNTS NOT PAID IN FULL IN 30 DAYS ARE SUBJECT TO A
FINANCE CHARGE OF 1.5%PER MONTH. MINIMUM FINANCE
CHARGE OF=1.00.(ANNUAL PERCENTAGE RATE OF 18°k)
Invoice No.:27969 Thank you for calling Rumpca Services
W�l�ome To City & County Credit Union PC FIRST Page 1 of 1
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Cit�Ull L'�lU\
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Member#: ��*••s�
Member ID:�
AddF@SS: 1623C UPPER AFTON RD SAINT PAUL MN 55106
E-M811 AdC��@SS:JANETOLSON62(c�MSN.COM
�Cr� edit Card Detail
Card Number: "*"""**"'**3812 Available Balance: 7,033.00
Next Due Date: 03/23/2012 Balance: 320.64
Min Amount Due: 25.00 Limit: 7,500.00
Current Activity
Transaction Description Posted
Date Tran Ref Number Date Amount
KINDLE-DrMercola39 866-216-1072 WA
03/01/2012 03/01/2012 0.99
2469216ED002P V9
UMPCA VICES INC 651-459-2896 MN
03/08/2012 --�:_- -- 03/08/2012 212.00
QFDCGOX `_
QVC 401927724601 4 OF 4 800-367-9444 PA
03/09/2012 03/09/2012 9.66
2461043EM03RTS6FE
Card History
Last Statement Prior Statement 3 Statements Ago
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Copyright OO 2012 CCCU(City&County Credit Union)-St. PauL MN (V7.10) � �
https://pcfirst.cccu.com/PCFirstlCards/CreditCardHistory.aspx 3/12/2012