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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesc��
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Minnesota State Statute 466.OS states that "...every person...who claims damages from any municipality...shall cause t�o�e pi�¢3et�Yed to the
governing body of the municipality 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 will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your daim,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 PAUL, MN 55102
First Name Bradley Middle Initial W Last Name Manor _
Company or Business Name N/A
- - — _ .� -- -- -- --
Are You an Insurance Company? Yes�N If Yes, Claim Number?
Street Address 6448' Oakwood Road
City Woodbury State MN Zip Code�5125
Daytime Phone 6( 51 ) 738- 6737 Cell Phone 6( 51 ) 303- 6498 Evening Telephone 651 303- 6498
Date of Accident/Injury or Date Discovered �-1��/�2 Time .� d� am pm/
Please state, in detail, what occurred(happened),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 for your damages.
A hugh branch fell off the boule�ard tree on the corner of har eG nd Marinn Gt_
The branch destroyed �art of mv chain link fencP_
The brance was coverin� the sidewalk. The citv crew came rn,t an�t �„t u.� the bra�ch
The city crew came out the nPXr da3�.aud—�tt� �nwn thP big tree
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 pl�w
� My vehicle was wrongfully towed and/or ticketed � I was injured on City properiy
� Other type of property damage—please specify Chain Link Fence
� Other type of injury—please specify
In order to process your claim you need to inelude eopies of all applicable doeuments.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL 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 and/or receipts for the repairs
ti 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 actual bills
and/or receipts for the repairs; detailed list of damaged items
�a Injury claims: medical bills,receipts
ta 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comulete this section
Were there witnesses to the incident? Yes No n ow (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? ST Paul Police Case# or report# I was worried about someone
hurting themselves if they tried to climb over the branch covering the sidewalk.
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 necessary, attach a diagram.
Corner of Marion and Charles St. 530 Marion St.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �� ��i� L-��y�3� � 1b
�dehicle Claims—please complete this section N/A � check box if this section does no�applv
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
Injurv Claims—please complete this section N/A �check box if this section does not apply
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
,' Wfien did you miss work? - -- �pr:,��i�e * `}
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 will not be processed.
Submitting a false claim can result in prosecution. Date form was completed � - � 7�—%�
Print the Name of the Person who Completed this Form: -. Bradl y W. Manor
Signature of Person Making the Claim:
Revised February 20ll
Ce�yLink webmail Mtp:��mdo3.quaztzsynac�:cam�ambra/h�pr,nrmessa�ee hd=3ssx 1
CenturyLink Webmail �a1�Q.�m
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Fwd: Bid for chain link fence
From:Jasa�Zar�cfet'<handyrr�an-z�tiodt3ail.com> Thu,Sep 06,2012 06:03 PM
Subject:Fwd: Bid for chain lirdc fpnce
To:brad�Chadyn9.00m
Sert from my iPFane
Begin torvrarded message: _
From:Jason Zarxier<handvman-zCa�hotmaiLcom>
Dale:September 5,2012 2:16:42 PM CDT
To:"bradfc�chaching.com"<bradCa�chachina.com>
Subject:Fwd:B&1 for d�n liek fenoe
Sent from my iPhone
Begin forwarded message:
From:Jason Zanc!!er<}��man-zCa�hotmai{com>
Dabe:September 5,2012 2:11:51 PM CDT
To:"brad(a�chacin�com" <bradCa�chacing com>
Subjec�Bid�or d�link fenae
Hey Brad her�e is ti�e bid for the ferxe sorry it took so tong.
To replace eNeryttrng e�aoept the posts which we talbed abait and the gabes vwa�d be$950.00
there wa�d be new c�hain link fer�ce and top rai�where needed and the oid materials would be
rerr�oved.
Thanks,Jason Zander
Zande�'s Handyrnan Services
612-282-1814
Any question feel free to call
Sent from my iPhone
1 of 1 9/7/2012 9:20 AM
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Hudson Paqe # Township
Hudsa� Grid # Ra�ge
S�r E.Vill�ume Ave. / South St.Paul,Minnestoa 55075 �omer Lot [J SedionlQuerter
���)451-2221 — Fax(65/)451-6939
Name �'Scs.� O r Data `� �� 20��
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Address Selespeaon�l�V •
City County State Zip
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Employer Hame phone� 1 P'icture No.
Job Site Addres:..��d ' J�Z +'�:°� s�" Work Phone t � Tinas: 109G Down
5076 St�A uP
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QUANTITY
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Down Payment: Check .#
Amt. Date
Expiration Date
Credit Grd#
pPO �� g�� ALL�
A SEftViCE CHARCiE of 1�i4`Xa P�� "'1O�h (lB�j(' M�°allr) will be applied
R �TERIAL AND INSTALLATION
on all past due belances• �s�ble for any and all colletticn snd legal costs
The purchaser shail be resPo st due. ��S Em1M�TE VAUD FOR 30 TAX
i�tu�red by Midwest Fer� in the event of thia bill becom'n9 pa DAYS FROM AdOVE DATE TOTA �QZm
Midwest Fence reserves the right to lien the improved ProPertY �f P°�^''�Ot
in full as agroed to in this controct is not received•
shdl bt Na sol�r+spo�wb�h of fhe avrner.Or+ner rtiponsible f or rem��l 01
ond l�nc�I�s.Myr P�►wM��� �normol�evnd caditiom•Sho�d�°d`r w exc�ssive l+ord�pp��W�
pMm�r r�+ponsiW�(w�stabli+bnro ro'*��the imtallotion oi tM}�na.This coMroct o+w 6ed in lhis connoct.A�chan0es�noda
obtf�vcAOns o��wry��wl+ic6 will ineerf�re M�.����i Mfp.Co.�hoN iurnah u^�Y M'°materiol a�bbo►spsti
sncounlend.oaMr ao�►�Po1'�di�iona�cods of such r��•s.
from N»o4ow sp�dfieo�ioes�I be bitlsd ot AAidwnsYs cwr�M
ri�is o.d�.wip b�ean.6hdhg e��P°���f�•MawOK�°�°MOi' Date
Cusromer Siynaturc
Salesperson's Siynatu�e
Date
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