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Martin ���C!���C� JU! 0 � 2012 NOTICE OF CLAIM FORM to the Cit�, � ,`.' (�aul, Minnesota 4.,4�: !� 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 afYer the alleged loss or injury is discovered a norice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demnnded" 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 mnch 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'. SEND COMPLETED FORM AND OTI�R DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL,SAIlVT PAUL,MN 55102 First Name �a���� Middle Initial� Last Name /�a�'�%� Company or Business Name, if applicable� Street Address l �O� C��'��M 1�ve • City S f-� /�GU/ State M N Zip Code $S/°¢ or Daytime Telephone (f r� ) B�s- `f 9�D Z qS-BSi1/ Evening Telephone(_) Date of Accidentl Injury or Date Discovered 6' ,-/Z- T�me �2 am 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 employees are involved andJor responsible. .. - � , � t7 7 � -� J J r C- �i` f' �? �n �-r� CD s� ' � e ,r ' Buv R'J' a VCa' c az�c ' ' b N —�—I��'f . 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 and/or ticketed � ❑ Injured on City property �Other type of property damage—please specify /o %/c f- ❑ 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 annlicable documents. This is a general ' guideline of what should be subnutted with a claim form,but it is not all inclusive. You may be asked to � provide additional information depending on your claun. 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 �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 All Claims—nlease comulete this section Were there witnesses to the incident? es No Unknown (circle) lease rovide their names, addresse d telephone numbers: �{°Z•9z6.92 4 7 If yes,P P C %n o� �µ►i�i . si s/ 89s. p 36.s o �. a/r��VF Were the police or law enforcement called? Yes Unknown (circle) ��pp� If yes, what department or agency? Case#or report# 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 helpful, attach a diagram. 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. 7� 2S Vehicle Claims vlease comulete this section ❑ check box if this section does not anulv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Numher - S�� ---�------- — Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims please comulete this section ❑ check box if this section does 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 are attaching more pages to this claim form. Number of additional pages � � By signing this form,you are stating tkat all information you have prnvided is irue and correct to the best of your knowledge. Unsigned form.s will not be processed Submittireg a false claim can nsult in prosecution. Print the Name of the Person who Compl this F rm: Bcc a a��i H Signature of Person Making the Claim: Date form was completed 7 7''�Z Revised Apri12007 Invoice �TORTH STAR Date ���� 6/4/2012 L2319 Plumbing&Heating Company,Inc. � Bi��To 62 South Hamline Avenue Saint Paul,MN 55105 Patrick Martin (651)699-2725 • Fax(651)699-3�0 1901 Chelton Ave W St Paul MN 55104 ; T�t►s Job Site Address Due on receipt 1901 Chelwn Ave W Item Description Work Pertormed by: Amount Labor Plumbing Labor Kurt 135.00 Replaced ballcock(Plugged) 1 �Ir, Labor @$135/Hr Angie's List... 5%Discount Off of Labor -6.75 Truck Charge Truck Charge 25.00 Materials Materials 17�- --- ------ --- -- -- -- 18.OQ Total s1�1.2s THANK YOU FOR YOUR BUSINESS! Please call Carol with billing questions. Payments/Credits $-171.25 visa and Mastercard Accepced. Balance Due $�.� Payment is due by terms of your invoice.Payments not made by tem�s of invoice may be subject w a 1.5°lo charge per month(or i8%per annum}.