Saint Paul Academy & Summit School REG�l�'��
� �Uhi 2 � 2012
NOTICE OF CLAIM FORM to the City of Saint Paul��,�'�i e`sb�a
� Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days afier 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 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'. '
5END COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,314 CITY HALL,SAINT PAUL,MN 55102
First Name �`�� • Middle Initial ��l Last Name �`�� N S J'v
Company or Business Name,if applicable SA►N� �Q h v�- f}c�1�E�"�.J � Su r� r`1 �; S�r�o �L
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Street Address � ��` `�" � � � � �`� � " t�\� �' �'-���"
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City �'�� � ' '� " �' � State � '� Zip Code `���� ''
Daytime Telephone(6 s 1 ) �SS` �} ( '� ,� Evening Telephone( )
��
Date of Accidend Injury or Date Discovered � � � '` Time �� �� am 1 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 empl yees are involve ,andlor re$ponsibl�r ,
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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 ❑ Vehicle was damaged by a plow
❑ Vehicle was wrongfully towed andlor ticketed ❑ Inj�red on City property
L7�Other type of property damage-please specify ;�-��c ��;;`����s.. ���1 �":'F e fc411�����--`� 1+- �
❑ Other type of injury-please specify
❑ Other type not listed-please specify ,
In order to process your claim vou need to include copies of all anplicable 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
C�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 i
i
All Claims—please comnlete this section '
�` Were there witnesses to the incident? Yes rNo Unknown (circle)
If yes,please provide their names, addresses and telephone numbers:
i
Were the police or law enforcement called? Yes :�No� Unknown (circle) �
If yes,what depaztment or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection, name of park I
or facility,closest landmark,etc. Please be as detailed as possible. If helpful,attach a diagram. '
N�.;�-;o; d c.���-��� c 4�t��E� � =r, -�� .��. G-u( � LLt .� � ..�t�� c c:
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Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction. ''� �'L-�
�
�
Vehicle Claims—please complete this section ❑ check box if this secrion does not applv ��
Your Vehicle: Year Make Model i
License Plate Number State Color �
Registered Owner i
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
L. Driver of Vehicle (City Employee's Name)
Area Damaged
Injurv Claims—please complete this section ❑ check box if this section does not anplv ;
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
L,f Check here if you are attaching more pages to this claim form. Number of additional pages � �
By signing thu form,you are staling that all information you have provided u true and correct to the best of your knowledge. Unsigned
forms will not be processed. Submitting a false claim can result inprosecution. �
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Print the Name of the Person who Completed this Form: �� � 3 ! .� ��� �
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Signature of Person Making the Claim: r�� �1��r�"�rI �L��'' G'
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Date form was completed � �1r �'���' '�`'' �'� xev�Prii 20o c �
\... °�.�/°�
Jun 14 12 12:23p Able Fence, Inc. (651)222-7737 p.1
�'( �v� �E� NUMBER
ABLE FENCE INC.
FREE ESTfMA7ES
78 ACKER STR EET EAST•ST. PAUL, MN 55117 DATE SO�D
OFFICE:651-222-4355• FAX: 651-222-7737 /
DATE
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We proposeto sell and install a ��/a��2 on your prope in accordance witfi sketch and quantit'es listed below.
��'EB�Gauge Wire��_��*Line Posts � " EndlCorner �.��-H Top Rail �p HighM��►;,fr���aType
Name ��� r�'vl /J������'� �/ Utilities y�� ,(�2v.vn �/, ��
Address f 7 /.� /��Y!!lU�t��i — �.� ,f� 3` �G' +�sW.,�-,a.oc�
/� Cross Street ���? � -
City �fi /`��-✓I �?�1/J—_County J�'
Office# ��� G�G "" /,��'� Zp .�3��f/b Map Location ��� " °i�/� — -
Cell# G����-� f��� ~Fax#Gr�'6S�'' C'��� � Knuckle up U Twist�p Tcp rail of fence to:❑ follow g=o�nd C7 be level
SKETCH
QUANTITY
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We are satisfied with ihe installation of our#ence.
� t Billing Addrzss.If Diffe•enY Thar Above:
Total ���
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By: �/4)✓j� �Pia'.���/c.'
ACCEPTED:
By:
PAYMEPlT TERMS: �"t"� f�� ����•=r
All quotations subject to conditions beyond ur cont�ol. Customer agrees to furnish building permils, property lines and stake fence
location.This quolation does not include clearing Yrees; brush or other obstructions from warking area. Excess dirt from post holes to
remain on job site. Able Fence to call Gopher State One Call. Customer is responsible for locating all underground obstacles not
located by Gopher State One Call.
GOOD FENCES MAKE GOOD NEfGHBORS!!! 's`~�:•'