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[r�struct�o�-�s for Filinc� IVotice af Claim to City af Saint Pa�l� � ;;
Minnesota State Statute 466.05 NOTICE OF CLAIM...(B)very person...who claims damages from any
municipality...shal!cause To be presented to the goveming body of the municipality within 180 days afte� the �
alleged loss or injury is drscove�ed 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 typing or printing your answer to each question in
the space provided. If additional space is needed, please attach additional sheets.
�FCEl1�ED
PLEASE RETURN THIS Office of City Clerk MAR 0 i z���
COMPLETED FORM TO_:_ 170 City Hall _ _ ____ _
15 W ICellogg Blvd ��; -- ;e�
St Paul MN 55102 ,
Your Name: ' l�Mn �Z ���°`
�treet Address: ���� �hl� � __ ._ _ � �yP� � _ _ _ _ __ _ _.
City: �Q�.�/ll� State: �✓\,�� Zip Code: SS/�.
Daytime Telephone: (�JZ? � /ZSS Evening Telephone: ( ►
Date of Accident or Incident: ��_�Day of Weel<: �� a Time: ( -�j� ar or .pm (circ�e onel ,
Pfease state, in detail, wl�at occurred and the circumstances surrounding the event. Indicate how the
City of Saini Paul is involved, and why yo feel the City is responsible.
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Please indicate your reason or completing this forrrl: - � .
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f-=1 Vefiicle accident f7 Other property damage (please provide specifics below) i;.;;'I:
� Vehicle was towed ; ;1;'
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❑ Vehicle damaged ❑ Other injury to person (please provide specifics below) ,:,��
❑ Slipped and fell on City property f'
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Please provide the names and telephone numbers of any City employees involved in this � '
incident/accident and how they were involved: ;
,
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(over)
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If your vehicle vvas involved, pj�ase complete the following: a,, ., ��/
Year, malce, and model: 2���� �tws •�U���.. License Plate Number. .�fl/ �
Extent and area damaged:
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Was a City vehicle involved in this accident/incident? Yes ', N� (circle one)
if yes, please compiete the following: Type of vehicle
Year, make, and model
� Color of vehicle License Plaie Number: -
Description of vehicle
Location of accident/incident (please provide specifics such as street address, intersection, cross streets,
park name, facility name, etc.):
'1N� �Z _ Ce_r� C��2 _
__Please draw or attach a_diagram if appiicable;
Please specify the nature and extent of the 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 vel�icle, lease submit two estimates.
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Were there witnesses to this accident/incident? Yes �ircle one)
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If yes, please give the names, addresses, and telephone numbers of the witnesses:
Were the police called? 'Ye�{�10 (circle one) If yes, what department or agency? •
Police report num�er: =
Please print the name of the r � � �
person completing this form: � �w.ow ,� �nt�
e
Please sign your narrze: I
Date form signed: '�— �2— � '3
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Risl< Mgmt Division - Revised 1-30-01 �r �r�
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