Castillo 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 municipality...shall cause to 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 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 DOCU SA NT PAULCMN 55102��
15 WEST KELLOGG BLVD, 310 CITY HALL,
First Name �C��
Middle Initial�- . Last Name 0�-'��►� i� ������
Company or Business Name � '� � ��
Are You an Insurance Company? Yes/�o If Yes,Claim Number? .� ; ��,���,
Street Address � � �8 ��'c� ���
City S� ��
State rn� Zip C o d e � SS1 ao
Daytime Phone(�)���-�Cell Phone(��)?Z��1 Evening Telephone((��)�-$—�
Date of Accident/Injury or Date Discovered �2- �3'�2- Time a /pm
Please state,in detail,what occuned(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�eS b�-
c1�c v c c�J�r, 1�c1 � hev� bo ��
� vov� �•� �!-h� r, � '�r 1ne_
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Please check the box(es)that most closely represent the reason for compleQnlg y vehic e,was damaged during a tow
❑My vehicle was damaged in an accident vehicle was damaged by a plow
`�,My vehicle was damaged by a pothole or condition of the street 0 MWas injured on City property
❑ My vehicle was wrongfully towed and/or ticketed
❑ Other type of property damage-please specify
❑ Other type of injury-please specify
In order to process your claim ou need to include co ies of all a licable 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-ulease comnlete this section
Were there witnesses to the mcident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Unkr►own (circle)
Were the police or law enforcement called? YeS � Case#or report#
If yes,what department or agency.
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 d�Ia�iled as possible. If necessary,attach a diagram.
r. -� J�Ks or�- i�n �-hu�-}- v a �u►,�
Please indicate the amount you are seeking in compen�sati or what you would like the Ci�to�d1onto resolve this claim
to your-satisfaction. bc V'�c�`^ � ��`�` ��
Z. ar� � s .
❑check box if this section does not a 1
Vehicle Claims- lease com lete this se 'on v` Model `i`n z�°`-
Your Vehicle: Year Z002 Make
License Plate Number O 1�� � StateY'n� �olor S�� V��
Registered Owner t
Driver of Vehicle �PG'��� Sk: O
Area Damaged �� vov� a�� ��1L �v2 Ov� dvi vev�5 S�C�-e...
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this section
check box if this section does not a 1
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
(provide date(s))
When did you receive treatment?
Name of Medical Provider(s): Telephone
Address No
Did you miss work as a result of your injury? Z'eS (provide date(s))
When did you miss work?
Name of your Employer: Telephone
Address
f�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
+� _ 1�- 12
,�,,r� �M o 1��n-e�
Print the Name of the Person who Completed this Form: ^
6 � 1 r` a--C f;/ l,
Signature of Person Making the Claim: �`�"1� A/ �- �``
Revised February 2011
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