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f�larch 20. ?012
CIT`:� i,LtRK
Sllari Moare,Ch1C
Citv Clerk
C'itv Ut'Saint Paul
310 Citv Hall
1 a Kellog� Blvd.. Vl��st
Suint Paul. MN 5�102
H:1ND ULLI\'LR[?ll
RE: T�tcun Radkcji+��iclr Irtjirrl�Occirrriu�;un Se1�terrrber 24, 2011
[)car Ms. �toore,
I'lease he ad��isrd pursuanC to th� requirement�of iVfinnesota Statute � 46fi.05 that� � �laim is
heina made a��ainst you arising out of an accident��-hich occ���rred on the above date involving
Tatum Rodk��vi�h at the Camo "I'��wn ��mustment Park. Tatum Rc�clkewieh, �� t���o ycar��Icl
minor child, ���as injured by a Penny Press machine at ihe Cc�mo To���i� A�1�us�ment 1'ark. �I'h�
yc�ung child ���as injur�d �ti�llen the ann oi�the machine struck his mouth. 1-Ie r�q�iir�d medical
attention as�� reslilC.
I would appreciate your prompt atlenticm to this matter so that���e c;an atte►�ipt to r�s�lve it
��i�ithout the r�ectssit}� of suit bein� tilcd. ifi}�ou have any questions please do not hesit�ate to
contaci me.
Respectfully,
KU,:Ek��--L. ,
``�� �
�' � . Kt�fiis�..
E�:I7C�nSlt1'CS
cc: Sara Gre���'in�. Esq. (�ia US i�lail)
T�ssie Rodke���ich (��ia 1.15 I�liail)
David Rodkc��-ich (��ia US Mail)
� l�t.?.��l..;��� l_i_(� ':tii)(i t:'�!V�h_12��1��' :�`�;I� �i'1!�F i;; ���rt!�l-(>,1�"l �.1i:�;�Ffi{)���;� i��ii:t ti�l-(�:�-
V�. Oef?.!`.illt_I>.�--£�.il!i.,'r..Sy.. ?Ei.
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesola Sla/e Slatufe d66.05 slales lhat"...every person...who claims damages jrom any municipa/ily...sha!(cause lo be presen�ed�o�he
governing body of lhe munrcipality within/80 days after lhe alleged loss or rnjury is discovered a notice s�a�ing�he time,place,and
circumstances�hereof,and!he amoun[ojcompensation or olher reliejdemanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question.If more space is
needed,attach additiona)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 OTI�R DOCUMENT'S TO: C`ITY CLERK, 15
WEST KELLOGG BLVD,310 CITY HALL,SAINT PAUL,MN 55102
Name:Tessie Rodkewich and David Rodkewich as natural parents and guardians of Tatum Henry Rodkewich
Company or Business Name: n/a
Are You Insurance Company?Yes/No If Yes,Claim Number?n/a
Street Address: 198 16'h Avenue SE,,MN 55112
Ciry New Brighton State Minnesota Zip Code 55112
Daytime Phone 612-281-7198 Cell Phone 612-281-7198 Evening Telephone 612-281-7198
Date of Accidend Injury or Date Discovered September 24,2011 in the afternoon.
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.
Tatum Rodkewich is a two(2)year old minor child. He was injured by the Penny Press Machine at Como Town
Amusement Park. He received stiches on his lip as a result of the injury.
Please check the box(es)that most closely represent the reason for completing this form:
D My vehicle was damaged in an accident o My vehicle was damaged during a tow
D 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 D(was injured on City
propecty D Other type of property damage-please specify
[xJ Other type of injury-please specify:Child suffered injury to mouth and lip.
In order to process your claim vou need to include coaies of all aoalicable 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
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.
Failure to complete and return both pages will result in delay in the handling of your ctaim.
All Claims-alease comalete this section
f
Were there witnesses to the incident? Yes
Tessie Rodkewich
198 i6'"Avenue SW
New Brighton.Minnesota�Sl 12
612-281-7198
Dave Rodkewich
198 16`h Avenue SW
New Brighton,Minnesota 55112
612-237-7869
Were tlie police or law enforcement called?no
Where did the accident ar injury take place? Provide street
address,cross street, intersection,name of park or faciliry,
closest landmark,etc. Please be as detailed as possible. If
necessan1,attach a dia�am.
Como Town
1301 Ntidway Parkwa��
St. Paul. MN ��103
Pennv Press Machine
By signing t/ris form,you are stating tkat atl infurmntion you liave provided is true and correct!u the best ojyour
knowlerlg� Un.signed jorms wi!/not be prnce�ssed
Date furm was completed: Marc6 20,2012
Print the Name of the Person who Completed this Form:
Daniel S.Kufus
Kufus Law
1G00 University Avenue Suite 313
Saint Paul,Minnesota 55204
6SI-645-9359
�����Signature of Person Making the Claim: �
Tess e Rodkewich naturat parent and�naardian of Tatum Henry Rodkewicf�