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Moon � NOTICE'OF CLAIM FORM to the City of Saint'.Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who cAaims damages from any municipality...shall cause to be presented to the governing body of the municipality within 180 days a�ter the all�ged loss or injury is discovered a notice stating the time,place,arui circumstances thereof,and the amount f 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 ezplain 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 BL�-�10 CiITY HALL, SAI�TT PAUL, MN 55102 __ : - _ � �� �:;�. First Name �(.pr U.b� IJ � Middle Initial �-Last Name �UO I� ��iE�v�� Company or Business Name 1`��PC N(�V 2 � � � Are You an Insurance Company? Yes,�N If Yes,Claim Number? o,rrv,r+�,�[ Street Address �'�s �I a I��f�Iv �E - Vv� � City��p�i�� State nl(,1v Zip Code � � / Daytime Phone(����Cell Phone( ��+Q�.VV{�Q�_ _Evening Telephone(___, - Date of Accident/Injury or Date Discovered �� I ���7. Time � I 1' W am pm . i ' —� � i 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 resP�onsible for your damag . �°i�( ���" "1(' � �lit 4�S �leV� �1 �!'A-I�L ._' .aiX uJ�2��— � . �.. �r l�r r,�CX v-�k-s a� r u.lobe s e.�S_ � � � r �}u��ec/ UY �C tN ts�I u � ;p-�,� �ect � -(�� 5 • a.u� . � c n�er"� � h d t+ esh�,-Ec hed Pldase check the box(es)�t most close represent the reason for completing ' form: � ���y��X y�.t�S . �My vehicle was damaged in an accident t ❑My veti�ie was damag�d dunng a tow ❑My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged hy a plow , ❑My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property �Other type of property damage—please specify �-pY1/l e- — WiA�er aw�c��� , ❑ Other type of injury—please specify In order to rocess our claim ou need to include co ies of all a licable documents. p Y For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of � your claim. Documents WII.,L 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 andlor receipts for the repairs O Towing cla.ims: 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 d�maged items O Injury claims:medical bills,receipts , O Photographs are always welcome to document and support your claim but will not be retumed. � Page 1 of 2—Please complete land 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— lease com lete this secNon Were there witnesses to the incident? Y N�Q Unknown (circle) Provide their names,addresses and telephone numbers: N o r �h�r'r WG�-� �0��''S ��I,t;i�v�b 2X Were the police or law enforcement called? Yes No Unknown (circle) If yes,what department ar agency? �(k Case#or report# _ � �- Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest 1 dmark,etc. Ple e be as detailed as possible. If necessary, atta a dia am. �i �� � , '���nr� -�vw� —T- - .,:_ .. Please indicate the _ ount you-are seeki in compensation or what yo wo d like the ity to do to resolve this claim __ _,- — -- -to your sa sfaction. y ( e(�1,. Vehicle Claims—please complete this section I�/� ❑ check box if this section does not 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 Sta.te Color Driver of Vehicle(City Employee's Name) ' ' Area Damaged . ' , Iniurv Claims—please complete this section � � � ❑ 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 � - - —�ad you m�ss work as a result of��our injury? Yes � No . When did you miss work? (provide date(s)) Name of your Employer: Address Telephone �Check here if you are attaclung more pages to this claim form. Nnmber 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 resull in prosecution. Date form was completed 1 � '1'1 11 Z Print the Name of the Person who Compl ed this Form: C 1 (�`� i n , �vo Vl Signature of Person Making the Claim: Revised February 2011 �1�Z C���tC����l.t� �QM �r �lkU l.� �l�1ArC1��Z SU S . I I�`���T�� ; ���C��� � -�o� �'N�'NS . p� � f�s� - 2�(n- �81 S � � HAMERNICK DECORATING CENTER Page: 1 1381 RICE STREET ST. PAUL, MN 55117 C') Telephone: 651-487-3211 Fax: 651-487-1514 � N � N W �! N • • • MOON, CLAUDENE • • 475 ARLINGTON AVE W ' ! MOON, CLAUDENE ST. PAUL, MN 55117 � ' 475 ARLINGTON AVE W I i � ST. PAUL, MN 55117 ; ; i - - �� � � � � ; , • •- �. J I Receipt Histo . ' ' 11/06/12 � CG212362 Receipt Credit Number Pay Date Cash Check Totai Finance Card Discount Payment Charge 3725 11/17/12 0.00 150.00 0.00 0.00 150.00 0.00 '� ; — 11/17/12 —11:14AM- Sales Representative(s): INVOICE TOTAL: $150.00 JODI POOLE Discount: 0.00 Payment(s): -150.00 Finance Charge(s): 0.00 BALANCE DUE: $0.00 -:; ��. - .:, .,.:=i�Y��; �._:.' �i�,. :rt';:u�,� - �; ��; �J r... , . �� `=::�;"_..,i�.� `��1 � _��'. . �E', . , i i. ...a.._"�I i.%�i =Jit �'-i'S. ._. � $��., �_._., �.. � t "�s� - ';i i'^—f:.��u! • �? �n - - _ � —� �`� ,.,... _,_.. _��l�i :'. .. ,_ ,=i+:. . �;�i�j,;' '� t '�:u'`. ., i;',�C�'a � P '-� ._:),.f .�`.i�c1�14�.i'r.�' `5�+�xi.i_�+ lL..� l ..._��� h F.�f }` +T _ ,�G�!�' ,._ .��. . _. �', _. � � �.,.. 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