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MAY 0 � ZQ12.
NOTICE OF CLAIM FORM to the City of Sai����"��l,r��nesota
Minnesota State Statute 466.05 states that"...every person...who clair»s damages fram any municipaliry...sha[l cause to be presented to the
governing body of the municipalitv within!80 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 qnestion. If more space is
needed,attach additional sheets. Please note that you will not be contacted by tetephone to clarify answers,so pmvide as
much information as necessary to explain your claim,and the amount ot 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 'J��✓� Middle Initial C— Last Name ��1�---
Company or Business Name ���
Are You an Insurance Company? Yes No If Yes,Claim Number?
StreetAddress `���Z ��l�f'�`��- c-+�S'f" K.c� _
City �r"��'t �� ��S State �N Zip Code �s`� f �
Daytime Phone(�71)��(3'�ell Phone( ) - Evening Telephone(_� - �I
Date of Accidend Injury o Date Discove�` �������' Time G-- am�
--�_�._
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel xhe City of Saint Paul or its employees aze involved and/or responsible or your damages,
I/r 1.;�� :,J'c�5 -{--o.v� � C-�'a-�r �r-.J c��� � -( +r'��a -t-v ��-t-
�"'i�J�- "f"L�t ���G...:J�4' F c� >•i— �c l�tc-�b� <��a_ _.�._ � �rc�c..
Ci�- �rt r�`"'�- . O�` �-X � �w "r� +� °
.
Ji- ..J . C �: S :%�.I..;c_I� �W: t G�'
(/{-SLt,:�. I�+V'+�C..✓L f+""'!G 1'a K../"P�^� � t1"+t"�_ Y v�-�C-- �i fZ�:0
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 was injured on City property
,�Other type of property damage—please specify L��''t��l� a�r.�.,.��-�tx��<�.� � -�`.%'�
❑ Other type of injury—please specify
In order to process your claim vou need to include couies of all aonlicable 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 aze encouraged to keep a
copy for yourself before submitting your claim form
�Property damage claims to a vehicle: two estimates for the repairs to your vehicie 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 biils,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 ctaim.
All Claims-ulease complete tlus section
Were there witnesses to the incident? Yes No ' Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? es� No Unknown (circle)
If yes,what department or agency? �(`�t�.� Case#or report# !�a���� Z--
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 necessary,attach a diagram.
�30 ��'_3�N �+.�.�..1.�.�( �.
Please indicate the amou t you are seeking in com nsation or what you would like the City to do to resolve is claim
to your satisfaction. `�s�'� O �Y-�'Oi�E=� � ��`` - � `�`�
�
r���5t� �t ►���'r--r---� t?�.�,.��(� S��e(� ��,« �e.�t--v.�
Vehicle Claims-nlease cot�plete this section ❑check box if this section does not annlv
Your Vehicle: Year �Z�''t'`� Make :����'y Model ��-�1���
License Plate Number l(� rt-T".t�—�State M t�� Color 'S>��/�r'
Registered Owner��-��-• ��
Driver of Vehicle �h� 1� �'Is—
Area Damaged ��!-�i� �f�h�t:_l�
City Vehicle: Year� Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-please comalete this section �heck box if this section dces not anvlv
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
,�Check here if you�re attaching more pages to this claim form. Number of additional pages �
By signing this form,you are staling 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 prosecudion. Date form was completed �f �_�/ � Z
Print the Name of the Person who Completed this Form: V'��''°� �`'`` �
Signature of Person Making the Claim:
Revised February 2011
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