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Mackfand g���:��'E� ��� � -� zo�3 � �'.'p`�`' ,..t� :�'-�,'.k 6 NOTICE OF CLAIM FORM to the C�ty of Saint Paul, ll�bn�eso�� Minnesota S�ate Statule 466.05 smtes that "...every person...w3u�claims daneages from any municipaliry...shall cause Io he presenied In the oot•rrning bo�ly uf thr�nwiicipalit}ivithin 180 duys ujeer tlee ullrged loss or injury is dis�ol�ered u noiic•r statnig tltr time,plure,mid circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by clearly typing or printing yonr 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 informaflon as necessary to explain your clsim,and the aruount of compensation being requested You will receive a written aclrnowledgement once your form is received, The process can take up to ten weeks or longer depending on We 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 /��)F��1 e�t'. Middle Initial /�Last Name , � �r!�,j��' C 'n C�` Company or Business Name Are You an Insurance Company? Yes/� ff Yes,Claim Number? Street Address!���f ._�h r'f� t>r r�r' e:f t?�° : City y5 cv r n f �'C� v/ State m,`nn�S�-l'C� Zip Code ` I C Daytime Phone(�F�I ?� Fz 1�:�3o�-Cell Phone(_) - Evening Telephone(� - Date of Accidend Injury or Date Discovered,J���/C� �� C.�/.� Time �a�"m�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 Saint Paul or its employees are involved and/or responsible for yotu damages. �(�a r• I.r:�[�S �-c�?��c� n» r� �h �r� i,:;'r�'� �J(;a �i�C�i�.� �>>�-��finc�i c �-q J1 ; `' U�c,r r, �n�S i.�n c! x1 r? c�n� h��� �� ;��� y7.,`3 a> >t� r L.� cr �C`�t G �(' f)��f ) ���)T' r�) /7/ '� L L )Ji� C� fo T/"�l�.r �` >t77 hY'' '7 l� 7 !` , l, n��,�; � � -�-�' -f L�--�---1�a--..-� � t.�_� XL , (: C L' ,� � ' - Yl l '� /�,� �P C_ 1,��; l� 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 ❑Other type of injury—please specify In order to process your claim vou need to include copies of all auplicable documents. For the claims types listed below,please be sure to include the documents inrlicated or it will delay the handling of your claim. Documents WII.L 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 Aroperty damage ciaims 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 � Towing claims:legible copies of any ticket issuad and a copy of the impound lot receipt O Other property damage claims:[wo repair estimates if the damage exceeds$500_00;or[he 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 Forrn 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 wimesses 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 depaitment or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of ark or facility, closest landmark,etc. Please be as detailed as possible. If necessary,at[ach a diagram. `�9 9 5�,Pi���rr1� c�t�c�e . c? v/ rr�,y� C/'e 5 5 ,��" "�,L.�_�.�1'� Please indicate the am nt,you e seel�ng in com sati r w at yo would like the City to do to resolve this claim to your satisfaction. Vehicle Claims please complete this section �check box if this section does not apnlv Your Vehicle: Year %9> � Make `I`l 7�G 1->e't 4 Model �c�1 c� � c� License Plate Number�f�l� � !y� State�-r,.fi Color 5;iv r-� Registered Owner /�"i c�� r�r ,� ��t C �.f R�i�� Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Ihiver of Vehicle(City Employee's Narne) .4rea Damaged Iniurv Claims Ulease complete this section ❑check box if this section does not apply 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(sj: 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 tMs claim form. Number of additlonal 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 fulse claim can result in prosecution. 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