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JA�I a �� 2(�13
NOTICE OF CLAIM FORM to the City of Saint Parr��;�����sota
Minnesota State Statute 466.03 states that "...every person...who claims damages from any municipality...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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. This form must be signed,and both pages com�leted. If something does,not apply,write`N/A'.
SEND COMPLETED FORIVI AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,290 CITY HALL,SAINT PAUL,MN 55102
First Name 1��'�r Middle Initial Last Name ��/J�i
Company or Business Name, if applicable lt,�/,!�
Street Address_ �-��.�'- /����s C�� �� �� �
City �� ,�G��{/ State /L'�/�' Zip Code S � �3��
Daytime Teleph�"��S/ ) ,���/- 5.,1%� Evening Telephone(�S/ ) 3��-/- ��% �
-�,.�_.,,,s.,
Date of Accidend Injury or Date D �< �'�� l7 Time 23 SE� % . /pm(circle)
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Please state, in detail, what occurred, and why you are submitti _. wh or how you �
feel the City of Saint Paul or its employees are involved and/or responsible.
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Please check the box(es) that most closely represent the reason for completing this form: �
� Vehicle was damaged in an accident � Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or coridition af the street . ❑ Vehicle was damaged by a plow
L�'Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
❑ Other type of property damage-please specify
❑ Other type of injury-please specify �
❑ Other type not 1'rsted-please specify
In order to process your claim you need to include�onies of all auplicable documents. This is a general
guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle,or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates,detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs can be provided but will not be returned.
Page 1 of 2-Please complete ahd return both pages of Claim Form
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Notice of Claim Form, City of Saint Paul,page two
All Claims–alease complete this section
Were there witnesses to the incident? Yes No �Unknown (circle)
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If yes, please provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No �Unknow�a� (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 facility, closest landmark, etc.' Please be as detailed as possible. If helpful, attach a diagram.
Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction. � �`7 �' �'c�
Vehicle Claims–please complete this section �heck box if this section does not applv
Your Vehicle: �'��-=,...,�.. Make Model
License Plate Num er__,, 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
Iniury Claims–please complete this section C�check box if this section does not applv ,
How were you injured? I
What part(s) of your body were injured? !
i,
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 I
Did you miss work as a result of your injury? Yes No '
When did you rniss 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 may not be processed. Submitting a false claim can result in prosecution. �/
Print the Name of the Person who Completed this Form: /��1� /�/?�?
Signature of Person Making the Claim: /�E�� y</?<1
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Date form was completed %� — �� — �.2 Revised April 2006
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________.
iST. PAUL Citation# 8 8$ ���G� ��� �
� STATE OF MINNESOTA-RAMSEY DISTRICT COURT IIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII
nd sa s: (IIIIII IIIII I
The undersigned,bemg duly sworn, upon his/her oath deposes a Y * $ g g 7 4 g 6 8 7 *
� Date of Offense ��� � ��` � '�'' Time of Offense �- � ' �
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� Veh.License No. � �` � + Yeae ` ' State f' Make Style Color ' '
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� Location of Offense: � ' ' "" � � � � �
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i VIOLATION: � SNOW EMERGENCY St. Paul Ordinance 161.03 FINE $53.��
� CN � ��_ .<�, �� .y
(Amount includes mandatory state surcharges of$13.00)
I Citing Officer Citing
' Officer Number Dept.
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! ❑Posted Night Plow ❑Day Plow ❑Plowed in(Windrow) :�Tagged Before Plow ❑Drove Off
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� OFFICER'S NOTES
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! ❑NO PLATE VIN:
i Citation can be paid at the Impound Lot.Please read the back of the citation for payment instructions.
� PROSECUTOR
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