Mason REG��vtu
pEC i � 2012
�� ������
����T�.�E OF CLAIM FORM to the �����aint Pau�; Minnesota
Mij� ,Q ta�,State Statute 466.05 states that"...everyperson...who claims darr�e�',frofn�sny mun�cipaliry...shall cause to bepresented to the
L�'��(v�ern�in¢?b��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 comper�ti��p�other relief demanded."
f� 'r.}a -�. , f�1 f + � . __ •
�i��se c�ol�p'"le�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 pmvide 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 dces 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 l 1 �C�tf'�-- Middle Initial�Last Name 1 1 I l��cS�''f
Company or Business Name� �� \ �f�YYI(\�,(l l.�
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address� `_ 'S� �t(`O o�
City �� a a�� �a�1�. State�� Zip Code �
Daytime Phone ( S{)�-��Cell Phone(f c�il )��-�¢LQ Evening Telephone(( `�I_)�- 7ti�2
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 S int Paul or its employees aze in lved and/or responsible for your dam ges.
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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
❑ My vehicle was wrongfully towed and/or ticketed � I was injured on City property
�Other type of property damage—please specify�,..�� t�o�!"'c� ,�,�t�.
❑ Other type of in�ury—please specify
In order to process your claim vou need to include copies of all applicable 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
• 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 complete this section
Were there witnesses to the incident? Yes No Unknown (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? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or f�3cility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. ��^�fCt, �oo ,`<1 �C`�
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.
Vehicle Claims—alease comnlete this section ❑check box if this section does not annlv
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 ❑check box if this section does not avplv
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 will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �'� � � ��
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim: ��/—�
Revised February 2011
Use Your -�"'� . �-�
B/G CARD REB,4�`E� '
� � ..,y�,
MEN�RDS — Oakdal�
3�05 Had 1 ey A�ve No rt h
Qakdale , MN 55128
KEER YOUR RECEIPT
RETl1RN POLICY VARIES BY PRODUCT TYPE
Unless noted below allowable returns for
items on this receipt wi11 be in the form
of an in store credit voucher if the
return is done after O1/08J13
i IIIII I III(II III I(III((II(II(I()II II IIIII II(I
Sale Transaction
4000 PSI SAKRETE CONCRET
1891098 2 �2.65 5.30
SCOTTSDALE MAILBOX POST
2155721 19.97
ELITE POST MDUNT STANDAR
2156925 15.97
,� „
SAVANNAH POST LT BLK
3563379 23.99
3/16X3"DBL FLUTE MASQNRY*
2362042 1.67
Octoberfest Sale (1 .97 - 0.30)
SCREWS FLAT HEAD 6X3/4
2332718 0.82
#6 WHITE ANCHOR 1"
2331162 0.66
TOTAL 74.37
WASHINGTON Co-MN TAX 7.125% 5.30
TOTAL SALE 79,67
' Menard Contractor Card 9000 79.67
052570
Swiped
Job # or Name : 24 e sandralee
TOTAL SAUINGS 0.30
TOTAL NUMBER OF ITEMS = 9
GUEST COPY
The Cardholder acknowledges receipt of
goods/services in the total amount shown
hereon and agrees to pay the card issuer
accarding to its current terms.
THIS IS YOUR CREDIT CARD SALES SLIP
PLEASE RETAIN FOR YOUR RECORDS.
THANK YOU, YOUR CASHIER, Jennifer