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Womens's Advocates � A��'�f�� , �1AY 16 2012 �lome�Sfldvocates, I�c. ,� �;n, �ti , .rI`�, �.P�..�.��, City Clerk 15 West Kellogg Blvd 310 City Hall Saint Paul,MN 55102 May 8, 2012 To Whom It May Concern, Enclosed is the claim form for the reimbursement of the fence that Officer Bob Winsor backed into on April 10, 2012. Women's Advocates is a temporary safe place for women and their children. The fence is a crucial part to maintaining that safety. Since the fence is for protection,there was an urgent need to have it repaired. If you need any further information please feel free to call me at (651) 726-5211. S' erely, �' ir ey i s—Johnson Faciliti ager � , � I � �� i� 1 � i i � i 1 ' �NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the goveming body of the municipality within 180 days after the alleged loss or injury u discovered a notice stating the time,plaee,and circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by cleariy typing or printing your answer fo 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 acl�owledgement 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 55 First Name �� ' � Mid�dle Initial�Last Name ��,�v� ► � ! �� '�y�C Company or Business Name� �1�'1L'��'l 5 If i.l � /r ' � �� ^ �'' �J 1 Are You an Insurance Company? es o If Yes, Claim Number? � Street Address 'J� � �'f'� � � Ci 5� , / ��,. .� State f�/�-� Zip Code � ��— tY �E; _ _ Daytime Phone �,1�' -5�/f C�Phone.((�)�_��T�'jl'Evening Telephone ( )__- Date of Accident/Injury or Date Discovered � � . �� -Time_�m��m Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indi why or how you feel t�e City of Saint Paul or its mployees are involved and/or responsible for your damages. :`'' � �' s��' °,k � � r �� ,� ; � �_, � � ,� � - s � � i C r��f �P ,h ,� , � � _ .`.S c.` �-- 7 � ��. , 1j C�/5 ,� ' c 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 vehicie was damaged by a pothole or condition of the street ❑ 1VIy vehicle was damaged by a plow �]My vehicle was wrongfully towed and/or ticketed ❑ was in,jured on C� property C��ther type of property damage—please specify �� i� 5 C t!I C �-�� ❑ Other type of injury-please specify In order to process your claim You 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 WII.L 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 $SOQ.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 actua.l bills and/or receipts for,the repairs; deta.iled 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 RECEIVED titA'� " � �012 -° 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? - �Y�s� No , � U�lrnown G� circle) _ Pro ' the' names, d esses.and:tielepho numb s: - t� �-}'�� -��-�.I!��'� - �� , �.� �-��- �. Were the:police"or law enforcement cal ed? - Yes ' �, Unknown' � --(circle) - ---- _ If yes,what department or agency? � � . '�'� �``°`;: , _ i,: ase#or�report# '(r� � �:''��.',�(�.�,�; 7 Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or acility� clos�st 1 ark, e�c. Please be as detai d as possible. If necessary, attach a diagram. "' ✓/� `,.�1 �' � f— � � �Ct `� ��- ° �r�- � Please indicate the amount you ar��eking in compensation or what you would like the City to do to resolve this claim to your satisfaction.��,�, ' Vehiele Claims- lease com lete this section � ❑ check box if this section does a 1 Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle �- -- Area Damaged _ _ __ . _: .__ _ City Vehicle: Year Make odel -_--- . _ __ . . - .- ._ ._. __ ,_: _ _ _ _ License Plate Number State Color Driver of Vehicl ' mployee's Name) Area D ed " _ In'u C ' s— lease com lete this section ' ` � check box if this section does not a 1 Ho� were you injured? _ � What part(s) of your body were injured? Have you sought medical treatment? Yes No . Pla � o Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): ' Address Telephone Did you miss work as a resu ur injury? Yes No _ _ , , . . . , . When did you�i.s (provide date(s)) Name��o r Employer: Ad�ress 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 processec� Submitting a false claim can result in prosecuhon..Date form was completed �� , ��✓�. Print�he Name of the Person who Complet` - 's For� : �k� �% `�-�}� t � . �.�,�� ,// �/ . ; : Sig�ture of Person Making the Claim: - f �"�'�`� t J�'�� , �--- � � � � � Revised February 2011 � MIDWEST FENCE & MFG. 52�EAST VILLAUME AVENUE INVOICE SOUTH ST. PAUL,MN 55075 PHONE(651) 451-2221 FAX (651) 451-6939 INVOICE NUMBER:14 3 S4 O Source: INVOICE DATE:O4/ZS�12 Order �52822 WOMAN'S ADVOCATE PAGE: 1 WOM�N'S P,DVOCATE so�o ATTN; SHIRLEY sHiP ATTN: SHIRLEX ro: 58 8 GRAND AVE ro: 58 8 GRAND AVE ST PAUL, MN : _ ST PAUL, MN 55102 5510?_ � �;� � cu�r i n �ta�� * SHIP VIA: P.Q.NUM$LR SHIPDATE: O4�'13�1� �Pfy��1T�' �:4��.��.� ' � � �'�'� �' DUE Dpl`�: �5��$��.'� OEJR OFtDE(�NC� ��- � �r, � TERMS: DUE ON RCPT $" ' � ,. _ , ��.. :SAI:ES!?�R��N �� ' . . �.� . � , � Rh.PAIR SECTION OF 1 . 00 1. 00 50�. 0000 50Q. 00 TREX FENCING DAMA ED BY POLIC CAR. - URGENT REPAIR T0 IRtTAIN SEC RITY R CEfVED APR 19 � 12 'HANK YOU FOR_ YOUR. BUSINFSS, WE APPRECIATE IT S�g��,q�� ., 5pp, �0 � ��.�r,�r :' ,� o. o o � �n�i�r�r�:�� 0. �0 �� 'C�f'It�.:d' 50 0.0 0 �rv�n�� r�vvvvh�w� uv�.. L:j (U b 'Midwest Fence&Mfg. Check Number: 23706 Check Date: Apr 25, 2012 Check Amount: $500.00 Item to be Paid- Description Amount Paid 143540 500.00 _------- — - � 23706� WOMEN'S ADVOCATES, INC. �� 1-800-908-BANK(Z265) Q►,��.r°"°ir.�. 688 dFlNND AVE Bremetcom 3AINT PAUL,MN 55102-2698 75-1041•960 (851)22T-9968 � S DATE AMOUNT � Apr 25, 2012 $500.00 Memo: � PAY � Five Hundred and 00/l00 Dollars TO THE a oR°ER Midwest Fence&Mfg. (� �� OF: 525 East Villaume Avenue South Saint Paul,MN 55075 AU11i0RQED SIONATURE i�'0 23706n' ��:0960104 LS�: 0665�� 3045��' WOMEN'S ADVOCATES, INC. 2 3 7 0 6 Midwest Fence&Mfg. Check Number: 23706 Check Date: Apr 25; 2012 Check Amount: $500.00 Item to be Paid - Description Amount Paid 143540 500.00 FRODUCT DLM10B U3E WITT181500 ENVELOPE PRINTED M U.SA A �