Vue �c������c�B���s �a� �ECi�c����.�otic� a� C[aiE�� �a �i�y Q� �a�F-�f Pa�€� . '
' ll9innesot3 State Statute 466.05 NOT/CE OF CLAIM...(EJv���,��ho claims damages from any
municipality...shall cause to be presented to the gove�ning body of the municipality �virhin 180 days after the
alleged loss or inju�y is discovered a notice stating the tim���c� �n�cumstances thereof, and the amount of
compensation or other relief demanded �
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Piease cornplete tl�is forr�i in its entirety by typing or printing your ans�Ner to each question in
tlie space provided. If additional space is needed, please attach additional sheets.
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- FLEASE RETURN THIS . Office of City CIer1� �-���
COMPLETED FORM T.�: 170 City Hall
( 15 Vil lCeliogg Blvd �
� St Paul MN 55102 f,.='
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IC�C �re S oua � __.___-
, ; ._ ___. _._ .
Your Name: „ vr�f� -
_ _.Stre�t Address:- - -� / ... _
_---_ --- --.....--------__.. -- - -- - --� -
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��--____��Or� �-jf __ ._. - .
City: s C�.,(.VL� �G� �C,� State: /�1 /�.� Zip Code: 5 .S�l 03
Daytime Telephone: �S/) ��` '�- G���/ , Evening Telepl�one: ( )
Darte of Accident or Incident: �7 � / �Day of Weelc S(.��1CfCc Time; � 30 ,�m r pm (circ�e one) .
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Ptease state, in detail, wliat occurred and the circumstances sur;ounding the event. Indicate how the
ity of,�aint Paul is involved, and why you feel the City is responsible. _
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Please indicate your reason for completing this form:
� ;�
G.1 Veliicle accident �-7 Other property damage (please provide specifics below) �;`;�:j;.
� Vehicle was towed �'�:i�,�
❑ Vehicle damaged ❑ Otl�er injury to person (please provide specifics below) ',���
;:I 4
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❑ Slipped and fell. on City property ;.,i,:!
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Please provide the names and telephone numbers of any City em�loyees involved in this ��;� �.
incident/accident and how they were involved: �' '�
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(over)
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If your vehicle vvas involved, please complete the following:
Year; malce, and model: License Plate Number:
Extani and area damaged:
Was a City vehicle involved in this accident/incident? Yes No (circle one)
If yes, please complete the following: Type of vehicle
Year, mai<e, and model
� Color of vehicle License Plate Number: -
Description of vehicle
Location of accident/incident (please provide specifics sucl� as street address, intersection, cross streets,
park name, facility name; etc.):
---._ .P_Jease.d[aw. or_attach. a_diagram_.!f..aPPficaU(e-------- ---_ - —._. ----- ---- ---- —.__ .:-- -- ...--•-- ---�------ --
Piease specify the nature and extent of tlie compensation or other relief you are requesting. Please
attach copies of any bills, receipts, ticl<ets, or other documents to support your claim. If you are
claiming damage to a vei�icle, please submit two estimates. .
Were t}�ere witnesses to this accident/incident? Yes No (circle one)
If yes, please give the names, addresses, and telephone numbers of the witnesses:
Were the police called? Yes No (circle one) If yes, what department or agency? •
Police report number:
Please print the name of the , /
person completing this form: � V � V LI Q� .
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Please sign your name: f
Date form signed: � � � �/ � �
�;, .
Risl< Mgmt Division - Revised 1-30-01 ''���I���'��
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