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NOTICE OF CLAIM FORM to the City of Saint Paul, Mint��.��
Minne,rota State Statute 466.05 states t/rut"...every person...whn cictin�s damages fi-om uny municipnlity...shall cause to be presented to the
go��erni�tg body qf the m��nicrpality within 1 SO duys ufter-the nlleoed loss or injury ie discovered cr notice stuting the time,pluce,and
circ�cnastanres thereof,antt the amowat of compe�tsntion or other relief denianded."
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 • �'Y1 � iddle Initial T�• Last Name T'��m��Q-I��
L' REC�lv�Ei
Company or$usiness Name o �T �r�����7 � S
Are You an Insurance Company'? Yes No If Yes,Claim Number? c�,�,�� � n �n1�
Street Address (_Ll2(�CL f. /V �^^�'?:r :�+� .-�!
a _ .: .�..,_,.;�.
City CJ� • C(,1,� ( State YY1� Zip Code ��J���
Daytime Phone(�)73 )7 Cell Phone�)�-��Q Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 1 � • � � � �-- Time` 2- �S am/�
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 responsible for your damages.
�L 1 S -Q(.r �S i r �v� ` Q vD� Gt.n
v� n a
✓
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
❑ Nty 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
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all applicable documents.
Far the claims types]isted 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 far 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-qlease comnlete this section
Were there witnesses to the incident? Y�� No Unknown (circle)
Provide their names,addresses and telephone numbers: ��L��S �G�r�-h�-�,i-
Were the police or law enforcement called? Yes � �.._�-� Unknown (circle)
If yes,what department or agency? Case#ar report#
Where did the accident or injury take place? Provide street address,cross street,intersection, name of park or facility,
closest landmark,ete. Please be as detailed as possible. If necessary'attach a iagram.
gs �C t�c�-�l i n e
Please indicate the amount are seeking in compensation or what u would like the City to do to resolve this cl��m
to your�tisfact'on. i�f l�'?'?I�UI"4/��'F. (� �['p t� �/',�� ��f��(��
Vehicle Claims-please complete this section �ck box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Colar
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Colar
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims-please complete this section �ck box if this section does not applv
How were you injared?
What part(s)of your body were injured?
Have y�ou 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 Em�loyer:
Address Telephone
0 Check here if you are attaching more pages to this claim form. Number of additional pages
B_y signing this fornz,you are statirzg that all information y�u have provi,ded is true and correct to the best
of your knowledge. Usisigned forfns will not be processed.
Submitting a false claim can result in prosecution. Date f�xvas completed l�• �-r- ��
Print the Name of the Person who Completed this Form: w�✓ �L�rn
Signature of Person Making the Claim:
Revised February 2011
RECEIVED 11108f2012 10:53
Nov 08 12 10:48p J.D.Windows&Doors Inc. 7637678989 p.1
J.D. YVindows & Doors Inc. � ��O t�E
11221 Arrawhead St NW
Coon Rapids,MN 55433 Invoice Number. 11389
invoice Date: �lov 8,2042
page: 1
Voice: 692�62-0086 Dup!"�ate
Fax: 763-767-8989
- ,�------------... _.... .. --------------
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Bill To: -- S�P�:
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Samir�roperties Hudsan Terrace
i 3759 Ct�agoAve So_ 395 LuelFa St.N
Mpls, MN 554Q7 St Paul, MN 55119
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� CusfiamerlD Cusbort�erPO PaymerrtTerms
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- 5PR Jennifer Net 3D Days_ --- _
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Sales Rep ID ,; ShQping Me#f►od Ship Dabe ' Due Dabe '
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Hand Defiver 1118I12 �_ 1218/'!2 �
_.._. _ - . . _ -- _ . —_..._ --- --- .. �ry 9- --_-� -- . ---- -
Quantrty ttem Descnphor� Unit Prlce � A�ou�t '
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J 1_OD Replace the broken ent door fass s�ze 37 300.00 , 300_00 '
114 x 76 3!4 _030 safety laminated c�e�
;glass� emergency Cut and install.
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SubtDtel i
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Sales Tax �
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TotallnvoiceAmount ' 30D.00
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ChecklCredit Memo No: Pay►meritlCredd Applied
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---- - -- 300.00
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Qverdue invaces are sub�ed�o late charges.