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. NOTICE OF CLAIM FORM to the City of Saint P,�l,�i��'�sota
- Minnesota State Statute 466.OS states that ° ...every person...who claims damages from any municipa[i�C ha!!cause to be presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a r�t���tq(��7�he.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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. 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 � d Middle Initial� Last Name '�1 �`�
Company or Business Name, if applicable
Street Address (� - �Y1. �l(� 2"1� -.`.�
City ��. � pu,) � State Zip Code
Daytime Telephone ( ��l �i�--- s��j� Evening Telephone (�( S� ) ��g-���v�
Date of Accident/ Injury or Date Discovered �, o�� S� � U� � Time �/pm(circle)
Please state, in detail, what occurred, 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 responsi le.
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Please check the box(es) that most closely represent the reason for completing this form:
❑ Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street O Vehicle was damaged by a plow
'�8(,Vehicle was wrongfully towed and/or ticketed O Injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
O Other type not listed—please specify
In order to process your claim you need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claim form, but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates, detailed list of damaged items
O Injury claims: medical bills, receipts
O Photographs can be provided but will not be returned.
Page 1 of 2 — Please complete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul, page two
• � All Claims— please complete this section
Were there witnesses to the incident? Yes No 3 Unknown (circle)
If yes, please 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 helpful, attach a diagram.
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Please indicate the amount you are seeking in compensatio om thi claim or what y u woul like the City
to do to resolve this claim to your sati faction. �.
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year �06 Make L�n�o l�. Model ��,� ���1�,�
License Plate Number �-13�7�C� 1, State �tG�! Color I� ' �
Registered Owner����.� �_ ��---� �n���G, �.(��Q�^
Driver of Vehicle ��I�c`��iy�e��, e �
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 �heck 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
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
O Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that a[!information you have provided is true and correct to the best of your knowledge. Unsigned
forms wil/ not be processed. Submilting a jalse claim can result in prosecution. �
Print the Name of the Person who Completed th' orm: ��1 e.l � � r
Signature of Person Making the C aim:
Date form was completed Z Revised April 2007
Citation# �,�� � y. u a �. f
ST. PAUL
STATE OF MiNNESOTA-RAMSEY RIStRiC'f CQURT } � �������������������������������������������}��
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7he undersigned,being duly sw�rn, upon h�slher oath deposes and says: * $ g g 7 q, q 6 4 7 *
Date of OMense d� Ib( J I� Tfine of Offense " ' � t
Plate �,I� Cotor ���' '
Veh.License No. ��� �� Year � Siate r_�� Make � � N C` Styfe � �
Location af Olfense:
oN ��I�R'Y �►►�w �`.�t'� ����4� ��� �
viou►TSOr�: '� SNOW EMERGENCY Si,Paul Ordistance 161.os FtNE $53.t?�
h� � O�� (Amount indudes mandalorY s►ate surcharges of$13.00)
�N 1 ��
Citing f Otticer � � � Qe�9 � � •
Otficer, ' Number
p Pasted IYight Pbw P..'�ay Pfaw D Plowed in(Wind�ow} B'l�gged Sefore Ptow O Drove Off
OFFICEA'S NOTES
p NO PLA7E VIN:
Citas)nn cen be peid et tfse Impound Lot.P1Base read the back o4!ha citatifln for payment Instruetibns.
COMPIJ�INT