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Strain RE��.l��� � � 012 , NOTICE OF CLAIM FORM to the City of Saint Paul, lVl�n�eso�a � M ��� "'Minnesota State Statute 466.05 states that "...every person...who claims damages from arry municipality...shall cau�e t����ented to the governing body of the municipality within 180 days after the alleged loss or injury is discmered 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 ctarify answers,so provide as much information as necessary to ezplain 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 CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAiTL, MN 55102 First Name_��.�L Middle Initial�Last Name ._5'��J�/ Company or Business Name R�S�'�p,y f _ -__ _ 11re You an Ins�a�a�ee Compzny? Yes/�N�} If Ires,Glaim Nutnber`� _ _ - - --- l.� Street Address /�4� �yL�j��/ ,S f ' City Qu1��,eD�t/� State� Zip Code S //� Daytime Phone( S/ ��j/17 Cell Phone(�/a�..� Evening Telephone(_� „�Gt� Date of Accidentl Injury or Date Discovered / o� 2 Time am/� � , Please state, in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you -_ _.-.---�'eel the Ciiy of Saint Paul or its.employees are involvec�and/or esponsible for your damages,._W�%�� yr�a„� �� u cf...� - � � ai y - s 't/ .� � � ? K p,(� ` o �a,�S' O � [c — MG� 61 O Cuirl . _ G�/�t OlJ ' �" 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 properiy �{3ther type of property damage-please.specify SQ� ���u..e ea- gDD i�'i'����'.� ❑ Other type of injury-please specify � � In order to process your claim youu need to include couies of all analicable 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 $500.00;or the actual bills a.nd/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 clanns:two repair estimates if the da.mage exceeds$500.00;or the actual bills and/or receipts for the repairs;deta.iled list of da.maged items �'; O Injury claims:medical bills,receipts , ^�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 --._�;_... i Failure to complete and retnrn both pages will result in delay in the handling of your claim. All Claims- lease com lete this secti '1 ' - Were there witnesses to the incident? Yes �` No Unknown (circle) Provide their names,addresses and telephone num ers: _�_�a/-f' � , .P i � s aL- � <` O` Were the police or law enforcement called? Yes No Unknown (circle) If yes,what department or agency? Case#or repo Where did the accident or injury take place? Provide stre address,cross street,intersection,name of pazk or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. r' S ,' .c ��� s '�' /� ..L /✓.2/� O2-r G!>' �s � �u� ct�s'! Pl�as�dica e e amount you are seeki in compensation or w at you wou d like the City to do to resolve this claim to your satisfaction. n��r����S.�� ha�t ti .b/Ie �.� �g d �/'2.r11 c�� � � -. Vehicle Claims-please complete this section check box if this section does not a 1 Your Vehicle: Year Make Model License Plate Number Sta.te Color Registered Owner Driver of Vehicle Area Damaged , City Vehicle: Year e Model i License Pl umber State Color �__ Driv of Vehicle(City Employee's Name) ea Da�naged ' � � - - - Iniurv�Claims-please complete this section eck box if this section does not a 1 How were you injured? - -T— � What part(s)of your body were injured? ,�31ru_ s� ,��/��,�/{Z-�. �o� •'•✓,i u /tyi_ � Have you sought medical treattnent? Yes No Planning to Seek Treatment(circle) j When did you receive treatment? �-Q�, �` /2 (provide date(s)) , Name of Medical Provider(s):^��i f,,�� - Address �5� elephone e.-s"/�� �3 .- �y�/ Did you miss work as a result of your injury? No` When did you miss work? (provide date(s)) __ Name_of your Employer, _ - __ _ _ ___ ' Address Telephone G�`6 � �Check here if you are attaching more pages to this claim form. Nnmber of additional pages�. �f��/ By signing this form,you are stating that aU information you have provided is true and correct to the best of your knowledge. Unsigned jorms will not be processed Submitting a false claim can result in prosecution. 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