Miller, Bernard NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented 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 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 PAUL, MN 55102
First Name Middle Initial ►�/• Last Name � L.L.�.� o�E��/ED
Company or Business Name 2 � ���
Are You an Insurance Compa ? Yes o Y s,Claim Number? '�—
Street Address � E� � ����
City�,T���.�� State ���V Zip Code �s/ J �
Daytime Phone(CO�)�'��Cell Phon��� -� Evening Telephone(�h�O ,���;�
O
Date of Accident/Injury or Date Discovered Time 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 i olved andlor responsible for your damages.
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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 '
❑ y vehicle was wrongfully towed and/or ticketed n � I was injured on City property �
ther type of property damage—please specify /�S�� �U� (�� �
❑ ther type of injury—please specify ',
In order to process your claim vou need to include conies of all apnlicable 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 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
O 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
O Injury claims: medical bills,receipts
O 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—nlease comnlete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes o Unknown (circle)
If yes, what department or agency? ase#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 ossible. If necessary, attach a agram.
10 �u Y-.� ��R-��r- � Cl�n 1�,�',����
Please indicate the amount you are see.k}'ng in compensation or what you would like the City to d°�to resolve this claim
to your satisfaction.�e������7f���'�_ �C�J�'f— 1
Vehicle ' s— lease com lete this section ❑c is section does not a 1
Your Vehicle: e Make Model
License Plate e Color
Registered Owner
Driver of Vehicle
Area Da
City Vehicle: Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur — lease com lete this section ❑ check box if this se ' does not a 1
How were you i ' ed?
What part(s)of your body were i ' �
Have you sought medical treatment? Ye Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephon
Did you miss wo s a result of your injury? Yes No
When did miss work? vide date(s))
Nam 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 ?
Print the Name oF the Person who Complet this Form: `�/ �� �. � �,�
5ignature of Person Making the Claim: �
Revised February 2011
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Mailsafe Locking Wall Mount Mailbox in Black-MSK00000 at The ... http://www.homedepot.com/webapp/wcs/stores/servlet/ProductDispla...
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Gibraltar Mailboxes Mailsafe Locking Wall
Mount Mailbox in Black
Model#MSK00000 Internet#100023993 Store SKU#
891800
Store SO SKU#559481
� (t2) WriteaReview
$59.97/EA-Each
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Free Shipping
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Zoom Views �de°S This item cannot be shipped to the following state(s):GU,PR,VI
Product Description Speciflcations Customer Reviews More Info Shipping Options
PRODUCT DESCRIPTION
The Mailsafe Locking Wall Mount Mailbox is made from heavy-duty steel and plastic for a durable impact and rust resistant construction.
The mailbox has an extra large capacity providing plenty of space to hold various types of mail and high volume mail deliveries.For added
securily and theft prevention,the mailbox features an incoming mail slot concealed by an aluminum flap and a locking outgoing mail
compartment with a cam lock.The unit inGudes an aluminum mail indicator flag,2 lock keys,mounting hardware,and instruclions for easy
installation.The brushed coated finish adds an attractive look to any residence.
• Constructed from heavy�uty steel and plastic offering durability and resistance to rust
• Extra large capacity provides ample space to house various types of mail and high volume mail deliveries
• Features an incoming mail slot concealed by an aluminum flap for added security
• Features a locking compartment with a cam lock for mail storage and added security against mail theft
• InGudes an aluminum mail indicator flag and 2 lock keys
• Mounting hardware and instructions included for easy installation
• Approved by the united states postal service postmaster general
• MFG Brand Name:Gibraltar Mailboxes
• MFG Model#:MSK00000
• MFG Part#:MSK00000
• Savings Center:New Lower Prices
Return To Top
SPECIFICATIONS
Assembled Depth(in.) 8.38 in Assembled Height(in.) 13.25 in
Assembled Width(in.) 16.75 in Assembly MinorAssembly
Required
Color Black Color Family Blacks
Convertible to post
mount No Impact Resistant No
Incoming mail opening Incoming mail opening
height(in.) 2 length(in.) 3.75
1 of 4 10/23/2012 7:43 AM
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The Home Dep Order Confirmation for 169535670
From:HomeDepot@homedepot.com Tue,Oct 16,2012 10:10 AM
Subject:The Home Depot Order Confirmation for W169535670
To
Please keep this email for your records.
Please add OnlineCustomerCare@homedepot.com to your address book.Learn how.
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\ ` P�4ore saving.MoredOing. Order Confirmation
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�FF�SHfPi�ING' + �FH�IN STORE PICK UP + �FREE RETURNS••
Order Number: W169535670
Order Date: Oct 16,2012 10:20:32 AM EST
Dear Bernard Miller,
Thank you for shopping homedepot.com.Please review your order details below and retain this email for your
records.You wiil receive a shipping confirmation email once your order has shipped.
Ordered Internet# Product Description Pr1Ce Amount
1 100023993 Mailsafe Locking Wall Mount Mailbox in Black $59.97 $59.97
Shipping Address:Bernard Miller,10 Ruth Street N.,SAINT PAUL,MN 55119,US
Shipping Method:Ground
Subtotal: $59.97
Shipping: $0.00
Estimated Sales Tax: $4.57
Order Total: $64.54
�
Billing Address: Bernard Miller
10 Ruth Street N.
SAINT PAUL MN 55119 US
Check your order status online at any time.Thank you again for visiting homedepot.com.
Sincerely,
1 of 3 10/23/2012 7:44 AM
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The Home Dep Shipping Confirmation f r W169535670 -
RETAIN FOR YO
From:HomeDepot@homedepot.com Wed,Oct 17,2012 06:05 PM
Subject:The Home Depot Shipping Confirmation for W169535670-RETAIN FOR YOUR RECORDS
To
Please keep this email for your records.
Please add OnlineCustomerCare@homedepot.com to your address book.Leam how.
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\ � h�oresaving.MOredpillg: Shipping Confirmation
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�FF�SHIPPING• + �FiiEE IN STORE P1CK UP + �FREE i�?URMS"'
Order Number:W169535670
Order Date:Oct 16,2012 10:2032 AM EST Returns Associate
Instructions
Carrier:UPS 1.Scan/enter receipt barcode
Tracking Number(s): 1Z40E35V0313769780 2•Scan/enter item UPC gi19 23 13260 10/17/2012
5270
Please note that this carrier only has access to package/shipment tracking information.
Dear Bernard Miller,
One or more of the items on your order W169535670 have shipped.Please review shipment details below.
Qty Internet# �PC Product Description �2tY Retum Unit qmount
Ordered Code Shipped Policy Price
1 100023993 046462025946 Mailsafe Locking Wall Mount Mailbox in 1 A $59.97 $59.97
Black
Subtotal: $59.97
Shipping: $0.00
Estimated Sales Tax: $4.57
Order Total: $64.54
���
Shipping Address: 10 Ruth Street N. Shipping Date: Oct 17,2012 3:42:19 PM
SAINT PAUL,MN 55119
Payment Amount
_ $64.54
Return Policy Code Definitions
Policy ID Days Policy Expires On
1 of 3 10/23/2012 7:46 AM
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