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Zika (2) ��c�� This claim form is being returned without having'f�eRn2 e��p��a claim for the following reasons: ��.,� �� Failure to provide a written description as to what happened and why a claim form was being submitted(page one). �ailure to rovide the ro er and re ' P p p qusred documentation (page one). Failure to provide a date of accident or injury(page one). Failure to indicate the a.mount of compensation being sought(page two). Failure to provide information about the vehicle involved (page two). Failure to provide information about the injury claimed(page iwo). Failure to sign the claim form (page two). Failure to print the name of the person who completed the claim form(page two). , Other: �� Q � , � �0�.� . � Please return the completed claim form to: � �� ..U� �� a � .�� . �U Office of the City Clerk � City of Saint Paul � �r 15 W. Kellogg Blvd. N�}- �,�, �',� � � 310 City Hall �� , � Saint Paul, MN 55102 �.1�-�. G�J�I� -�C�c- ��. 5�n.e,�t'�,�'s o c-- ,4-�Q If you do not return the completed clairn form with the appropriate documentation or information completed, then a claim file will NOT be established and an investigation ��Q . WILL NOT be done. In other words, NO FURTHER ACTION will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances. F�EC�IVEC� . c�� jJ�3 MAR 2 e 2012 ia"b��`� NOTICE OF CLAIM FO��e�-1�City of Saint Paul, Minnesota Minnesota State Statute 466.05 sfates that "...every person...wlio 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 egplain 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 CLER�, 15 WEST KELLOGG BL�D, 310 CITY FIALL, SAINT PAUL, MN 55102 ��`?��!=p Mid�le Initial 1� T ast Name �j� Company or Business Name (�t%� / Are You an Insurance Compan Yes/ o If Yes,Claim Number? Street Address�/�� /r�Sf�s'/� �j ,� �� City t�W/� �� te �IV Zip Code �S - Daytime Phone-(Z��ZZylf, .Cell-Phone�- - . Eve,ning'Telephone( ) . Date of Accident/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 ►� f 1 the�of�t Pa�il�ox its:e�ploy��aze involve�and/or responsible for your damages.�, i�1 g th (�'� � �� '� S C � r � Y� S ' h . � �' � ,� � s:� - a ; Cw+-�' �� ,�— � � ih � � , ,� � 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 pr erty �'Other type of property damage—please s ecify S -�' �� -� ❑ Other type of injury—please specify In order to process your cl ' youu need to include 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 WIIJL NOT be returned and become the property of the City. You are encouraged to keep a copy for�ourself 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 irnpound 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 Q 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 ' Unlmown (circle). „ vide the' names�ddresses d�ele hone bers: Were the police or law enforcement lled? Yes No Unlrnown (circle) If yes,what department or agency? Case#or report# . Where did the accident or injiuy take place? Provi e sfreet.address;cross street,intersection;name of park or facility, closest landmark, etc. Please be as led as ssible. If necessary, attach a diagram. cb�� 5 tY1Y�s �1—�c��('�-�' Please indicate the amount ou are seeldng in compens tion or ha.t y u Quld like the City to do to resolve 's claim to your satisfaction. - � (J�',i'1Q� c� ` �/e ` ' ��a� �,�y�� Vehiele Claims— lease com 1 e this section D check box if this section does not a 1 �� Your Vehicle` Year I Q Make Model II / License Plate Number � �� ('-�-(��,;/ I �'�'�- State Color �� Registered Owner ( Driver of Vehicle `Z i � `�.�� J I � Area Dama.ged_ � DO �� i City Vehicle: Year Make Model .._ _ _ ,.. ,,_ � License Plate Number State Color , ^a`�,C Driver of Vehicle(City Employee's Name) �'� / Area Damaged Iniurv Claims—please comulete this section ❑ check 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 Did you miss work as a r�sult of vn,ar in;»ry? ,. ' Yec �.r� When did ou miss work? �:,��i' Y ,� �, _ (provide date(s)) Name of your Employer: �;� � ` ��-,.' Address - "� Telephone ❑ Check here if you are attaching more page�'��Ft��iis C�a�in form �Number of additional pages :,:,;tZ>'.=�° J 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�"" �� '— � � Print the Name of the Person who Completed this orm: _J�� Signatnre of Person Making the Claim: Revised February 2011 � �l� �. Mississippi View Apartments 11020 Mississippi Boulevard NW Coon Rapids, MN 55433 (763)427-4700 March 8, 2012 ; _ �+�,� ��,� . . - � 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 ather questions you have please contact the off ce arid ' � we will assist you. Thank you. Sincerely, _ Penny Seaver _ � �� 4 �-,'f 1 ��_i F T1 r 4 �... &�.1 i�' l _ev��(�.� Community Manager 763-427-4700 ,�� 2�� r ,��k� ; � ; ,��.,;� '� - � - �-� :�': ,:t.,; - i � � � �