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Pyeh . • �E��C� NOTICE OF CLAIM FORM to the City of Saint Paul, ll�n�e�o�3 Minnesota State Statute 466.05 states thar "...every persorz...who claims damages from any municipality...shaU ca �to the � governing body of the rnunicipality within 180 days after the alleged loss or injury is discovered a notice statin�g�nn��d circumstances thereof,and the amount of compensarion or other relief demanded." � I Please comptete 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 BLVD, 310 CITY HALL, SAINT PALTI., MN 55102 First Name Maung Middle Initial Last Name Pyeh Company or Business Name Are You an Insurance Company? Ye�If Yes,Claim Number? I Street Address 1644 Woodbrids�e St City Saint Paul State MN Zip COde 55117 Daytime Phone(651)269-4735 Cell Phone ( } - Evening Telephone(_� - Date of Accident/Injury or Date Discovered 2/11/2013 Time 7:30 AM am/pm Please state,in detail,what occurred(happened), and why you aze 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. M�car was towed for a snow emeraency.even though it was correctly parked in iront of my house�address above). I snoke to Henry Ung,who verified the mistake and said the costs would be refunded. I paid the ticket and imr�ound fees totalin�S272.50. The license�late number is UUXS11 and the ticket was issued on 2/10 or 2l11. �elich ic net m�firct lan9��,ce I have acked m�friend,Eric Everman,�heln r_celv _fhis icc� _and hic nhonP n �mtY+r is lisfrari ahr�vP- � 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 propeRy ❑ Other type of property damage—please specify ❑ Other type of injury—please specify ' In order to process your claim vou neec�to include conies of all aaalicable 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 c�amaged 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 I ` � I�, Failure to complete and return both pages will result in delay in We handling of your claim. All Claims—please comQlete tWs section Were there witnesses to the incident? Yes � Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes � 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 facility, closest landmark,etc. Please be as detailed as possible. If necessary> attach a diagram. 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. S 72 50 Vehicle Claims—please comalete tlus section 0 check box if this section dces not applv Your Vehicle: Year 2000 Make Honda Model Civic License Plate Number UUx�11 State M N Color Tan Registered Owner Mauna Pveh Driver of Vehicle Area Danlaged No damage just reference info for the ticket. City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injurv Claims—ulease complete this section �check box if this section dces not auplv 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 forrn. 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 2/12/2013 Print the Name of the Person who Completed this Form: Eric Everman Signature of Person Making the Claim: � Revised Februazy 2011 5��'�Er S''�r»y". _ �� a ye' sr ww�. iwouro�or a3e sar� cHare� an SAINT PAI�, fN. 55107-2A60 651-266-5642 Merchant IU: �063�i144 Ters ID: 6017340000800638014486 Sale XXXXXXXXXXXX��3 VISA EntrY Method: S�iped Total; � ��.� �t� � g2ilii13 14:23:18 Im q: 8666� {� Code: �l�i: � pvor�(� Online �`� . ::�;:- -- c�w f'`' .: �.. r� .� �.� - � , _ _�� _;:�� " ; A . y�� /•` �� '� . �.:�V� y��+f+�� -- -� ��s�� ._.� ��+-.,, °� QQQ < s�z�' `� ��: ' � ��. �: . . .. �� .. �� . ��, x�; < M M! � � � � � � � � o W � � �. V a � �e a� f.. � $ a � � a > � o � V � Lj,J � J �- V a° � � � � a Q � � � � Z � T � Q \ � r /► � T fi _3G '��°�� v?�s�1....��=.,,j'£''�$ :=`l. ^2' v W3�,�I, ,.� '� l � � � O � " � � � � � � � � � � p > a U � a Y'�>d ... p .�,Y�g�. � � .y� d �� `_ r�* �1�' , � � �� ¢�� '�'� � ��,. - - .__._----- - ' � .. ��.. . 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