Wallenberg , . . �..�`'��t::3..�
NOTICE OF CLAIM FORM to the City of Saint`�fi�u�,��nesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municip�ItFjl.�sh��i�be presented to the
governing body of the municipaliry within 180 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 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'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: p�
CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL,SAINT PAUL,MN`S5�l�i'�[�1
First Name ���� Middle Initial� Last Name /,1��itJf�p/l�� � 3 ?�
�2
Company or Business Name, if applicable rv1TY�"I �t�r,
Street Address � ` �l , G/IZA�J� ��� �V�
City���,1� �P���! State `;,�s✓ Zip Code S�S^��si
Daytime Telephone (���) ������ Evening Telephone ( )
Date of Accident/Injury or Date Discovered 7 — �G� —/ 2. Time ��O am/(�im�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 and/or responsible.
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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 and/or ticketed ❑ Injured on City property ,
�Other type of property damage—please specify C!�t�Sf�S. �
❑ Other type of injury—please specify j
❑ Other type not listed—please specify
In order to process your claim vou need to include copies of all appli� �"��C„�'�,� ������
guideline of what should be submitted with a claim form, but it is not� �� ��� _,i - � - � �t-.: �
provide additional information depending on your claim. � VU. �,���M�.�R�'
O Property damage claims to a vehicle: at least two estimates w i �� � :
actual bills and/or receipts for the repairs ��j�.l� C�►.�:��t...
O Towing claims: legible copies of any tickets issued and cop • �.���.
�Other property damage: repair estimates, detailed list of dan �����... �t'""'�•
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 p
Failure to provide a completed claim form will resul
��.�,�tl�e���...
Notice of Claim Form, City of Saint Paul,page two
All Claims-please complete this section
Were there witnesses to the incident? Ye No Unknown (circle)
If yes, please provide their names, addresses and te,l��ho e numbers:
Ca r�J6i..�r.�. Ckn ,' s �„�l��f��,��
Were the police or law enforcement called? Yes Unknown (circle)
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.
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Please indicate the amount you are seeking in com,�ensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction. 1�� 5-"9 °° hi/f ,�j1g�7���ec�
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Vehicle Claims-please complete this section ❑ check box if this section does not a�plv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniurv Claims-please complete this section fd�check box if this section does not applv
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 that all information you have provided is true and correct to the best of your knowledge. Unsigned
forms wiU not be processed. Sub�rtitting a false claim can result in prosecution.
Print the Name of the Person who Completed this Form:�� �►An ��A /r�e.cJ✓e��
Signature of Person Making the Claim:
Date form was completed � '"� �/ 'L_ xe��sea APrii zoo�
r-ieaitnrartners uptica� `"�"" �` a�ds'i'��a }
401 Phalen Blvd. � MRSIERCARD
St. Paul; MN 55130 �'�8�1 # _
(651) 254-7558 Doctor : 40702/Veire SALE
RECORD q; 1S IIIU; �O6 1S
' : 32306713 OATE, FEB 11� 12 TI�; 18 96
BAiCH� 689
AU1N: 06 31
Patient AV$ RESPOHSE� Y- '
Richard R Wallenber
Address Account Number
ADORESS AIIB S DIGI1 ZIP �11CN
24221 Durant St NE 2173531
East Bethel, MN 55005-9602 TOTAL �3pp.pp
` �
Social Sa�urit;� Number Date of Birth i
OS-21-1955 I qGREE 10 PAY A80VE 10iA1 AI�roUHi
Home Phone work Phone RCCORD:NG 10 CARD ISSiJER A�REE!'IEII?
tr,EQCHFfIi AGREEhiENT If CREDII !J0�1��ER
(763) 444-4755
cusrar�R coP�
Code Description Amour��
� #5048 Frame 204 .61
HP Frame Discount 35% Discount � 71 .61-
Frame 0 . 00
Coupon 25/50 Exp 3/31/12 Discount 50 . 00-
#5t}48 Spectacle Lenses 276. QO
2 Polycarbonate Trans Progressive '
' Accolade _
#TGY
•� • TOTAL, : 3 5 9.0 0
_ _ _ _. __ _ _ .
__ _ _ _ _
MC1.8 E#2032� 300 . 00=
BALANCE DUE THIS. VISIT 59 .00
�'�
HF SC OPi1C�,_
401 PHAIEH 8LU0
SAI81 PR�I� MII. 55130-5
1ERI'I:fIPI ;.�.; OOi?3��Q�'ti1���3:i'7pB"�
PIERCHAIIi k� 3G�1�31%0�8
h�SiERCAR�
�#��������6429
_ SALE
RECORD q� 1 INV� 000001
DfliE� FEB 18. 12 tIl•IE� 07:51
� BPiCH� 692 Previous Bal 0 .00
A�iH� 028466 Charges 359 . 00
TOTAL �59.pp Payments 300 . 00-
New Balance 59 . 00
RICHRR� 41ALLEf18ERG �