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Zika " �EC�ivEa G-�� n MAR 2 � 2012 ��-b�� NOTICE OF CLAIM F0��1�City of Saint Pau , 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� Middle Initial 1� Last Name �/� Company or Business Name W� !� C 1 Are You an Insurance Compan Yes/ o If Yes, Claim Number? Street Address ��L� �l SS�S.S��11�� City I,VUf� �1� State vVl � Zip Code �,� . Daytime Phone(Z(� �°C�_Cell Phone ( ) - - Evening Telephone( ) - Date of Accidenb Injury or Date Discovered �Z � Z Time 1 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. 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 wa njure o�?`�ity property 6r Other type of property damage—please s ecify � S '�' "�d�l (�' t Y2�'4�C�� ❑ Other type of injury—please specify f� _ ��— �n��(�S' �� In order to process your clai vou need to inc ude copies 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. 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 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 andlor 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? Yes No Unlrnown (circle) P vide the' names�ddresses d�tele hone bers: Were the police or law enforcemen lled? Yes No Unlrnown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provi e street address, cross street, intersection,name of park or facility, clos��d�mark, _e�jtciYP�s��e b�as 'c�il�Qssible. If necessary, attach a diagram. -�— Please indicate the amount ou are seeking in compens tion or hat y�ou�upuld like the City to do to resolve is claim to your satisfaction. 'E� � G�,� � �+ �+IC' UP .�—S , . �--_ - t_ _�- Vehicle Claims- lease c m lete this section ❑ check box if this section does not a 1 Your Vehicle: Year 1 Q Make '� Model , License Plate Number � �'1�- State�,�Color ('-�(� �� n _ Registered Owner ��\v� Driver of Vehicle �Z-� ' �- �` � Area Damaged � UO `L�� City Vehicle: Year Make Model _ _ __ License Plate Number State Color �`�,C�' 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 inj ured? 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 i Did you rniss work a��flf�onr,�--��"'—'T'?-- — -- Y?s- - - -N� - - --- -- ---- When did you miss wark? (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 knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed J' l -�°( `- � � Print the Name of the Person who Completed this orm: �_ly'�I�iL-WC �G k-� ' Signature of Person Making the Claim: Revised February 20ll � t�`--�.. � Mississippi View Apartments 11020 Mississippi Boulevard NW Coon Rapids, MN 55433 (763)427-4700 March 8, 2012 �., c�+�r �,aa� _ ___ �- r� -- 11020 Mississippi Blvd NW #111 Coon Rapids, Mn 55433 . Dear Star: � Here are the key prices that you asked for: Key fob: $50.00 Apt key: $35.00 Mailbox key: $15.00 Any other questions you have please contact the office and we will assist you. Thank you. Sincerely, Penny Seaver Community Manager 763-427-4700 f;;� ,f/ ,;;` ,�. ,. `�; _ t °�,>; ,� '.�..`,�' �.."`'' ,� '�-->, �-.. t� f, � `,r � ��,�`� � °� .�' � "� � � ,�' �.� ��`� �� .._. � � �� =� ��' � � � �� , , �,�,� .�" �� ,�� - - � � . w _ , ::� -`� �a. _— �� C� �� a '� � __ � � ��[ � � � � � � �'�' � � � � ��. � �� . , � /(� ��`' `� �� - � , � .� 2 (� �