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Mason �Ec���vt►� ! p�C i � 2012 -�� ;����,� ,�E��TI,,CE OF CLAIM FORM to the ����'f�aint Pau�; Minnesota Mi ta,$tate Statute 466.05 states that "...every person...who claims dam�e�'fro`re�sny municipality...shall cause to be presented to the �v�rr�n�b��the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of comper��np�other relief demanded." !� -r�., .�y _. 'r.,e ► " t_,_ . ; -��•- �I��se col�nplet�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 �ITY HALL, SAINT PAUL, MN 55102 First Name l 1 �C�1C�'--- Middle Initial�Last Name I 1�11��6Y1 C�mpany or Business Name � I 1l��� v�.(1 U Are You an Insurance Company? Yes� If Yes,Claim Number? Street Address�JQ�, 1S� �`��52� City ���a�.�� ��i("K�. State �o Zip Code� Daytime Phone( `.�1)�-�Z Cell Phone((,��L)��-c}�(slo Evening Telephone((�`L)�-�2 Date of Accident/Injury or Date Discovered Time am 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 S int Paul or its employees are in lved and/or responsible,for your dam ges. r � � C e ^ � Please check the box(es)that most closely represent the r�ason 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 rnr�►� ��t'� c��,��"'�,,�,�c�. ❑ Other type of in�ury—please specify In order to process your claim vou need to include copies of all anulicable 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 • 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 damaged items O Injury claims: medical bills,receipts � � O Photographs are always welcome to document and support your claim but will not�`eYet�rded. 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—please comnlete this section Were there witnesses 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 department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or,f�cility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram cY� �'C�, �oo,�,k�� Please indicate the amount you are seeking in compensafion or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims—nlease complete this section ❑check box if this section does not aunlv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—nlease complete this section ❑check box if this section does not avvlv 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 yaur Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. 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 ��'� � � �� Print the Name of the Person who Completed this Fotm:��_C 1��`'� Signature of Person Making the Claim:�/—� Revised February 2011 � Use Your =� v. ��. B/G CARD � REBA�'E �� '- r �' .�� MENARDS — Oakdale 3205 Had 1 ey Ave No rtl� Oakdale , MN 551�8 KEEP YOUR RECEIPT RETURN POLICY VARIES BY PRODUCT TYPE Unless noted below allowable returns for items on this receipt will be in the form of an in store credit voucher if the return is done after 01/08/13 i IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Sale Transaction � 4000 PSI SAKRETE CONCRET 1891098 2 �2.65 5.30 SCOTTSDALE MAILBOX POST 2155721 19.97 ELITE POST MOUNT STANDAR 2156925 15.97 _ „ � SAVANNAH POST LT BLK 3563379 23.99 3/16X3"DBL FLUTE MASpNRY� 2362042 1 .67 Octoberfest Sale (1 .97 - 0.30) SCREWS FLAT HEAD 8X3/4 2332718 0.82 #6 WHITE ANCHOR 1" 2331162 0.66 ; TOTAL 74.37 � WASHINGTON Co-MN TpX 7.125% 5.30 ' TOTAL SALE 79.67 Menard Contractor Card 9000 79.67 052570 Swiped Job # or Name : 24 e sandralee TOTAL SAVINGS 0.30 TOTAL NUMBER OF ITEMS = 9 ' GUEST COPY � The Cardholder acknowledges receipt of goods/services in the total amount shown � hereon and agrees to pay the card issuer accarding to its current terms. THIS IS YOUR CREDIT CARO SALES SLIP PLEASE RETAIN FOR YOUR RECORDS. THANK YOU, YOUR CASHIER, Jennifer CONTRACTORS I NVOICE � WORK PERFORMED AT: r���� � � � �: .��,% � ,�. � � �> x � �-� ��; .� `� .^,#;. :�r - � ���� �.:`�¢:�...�a��^�� � �'� r� ��° � '_ � � f - . � . - _ � � '` � ,.'. ,�, �, ����r� d �+ + .. . s �. _ -•: ,�. ;�;�,�: ��F � # ,� ;��� �����, � �'�,� ':� _.. . � ' • � �� . � ,� , : �. , _..,..._.. ... _ ___.�.,.. � � ��n�� �n t. e y � � � -� '` �` � _ tis.. 5� � �' _ 'x ' � �,M�" s ar -� .�.� ���*. �. „� s��x '� �-� q,:-� �u�,+;,. c�',; ,, �. . ��'„' " �°r�� - . ���` x .; ��s �. , '�`� � !'1,.�� Y.:� .f x, .w r' ���k�:�. -� �{ y x�, `�' 'Y'��t�°�` _ # � '� . .�; �� 1 ..r - M1�. c � �._" F� �= �t^•�a�. �'Y _�Js. � �a�1 . � $` s' ' � �� :, ? ^F s a<� _ , .� _ : �� .� �gY''.�+�p, Fs�,f� tt.�� r � �� ..m r 4.- ' - " ** � .. '�' 2 'ne ' k /� ' 'T � �c ti�� fi'� ..�. .F+�� � � � '^li � y�� � Y u;• � 1 � �k ._ _ _ ' - v i �'�ep N 7` '�+q5 .. _. .� . . .r � r .i.�. y: r.� S � _ . .:'¢ ..���.. ���-�.�� . : � . _ ;�� _ _ � _ ...� � : ��:�-�. �� ��. � .,� : - �i�.�-� i�t S�-.t t t !�'t,tn..a�S -- (� �c.,��.�. � � � , , ,_ �.�_� , . .,. ��� , , ,,,� /��3/ �i This claim form is being returned without having been set up as a claim for the following reasons: Failure to provide a written description as to what happened and why a claim form was being submitted (page one). !� Failure t provide the proper and required documentation(page one). � �� � � yd-wc '�a�o 0�2 c�a'`�s- � �Failure to rovide a date of accident or injury(page one). G��2P�t r-c.�'r�4 5�i.¢ G�rsfi^u G�`u�j c�� , ��'I a Failure to indicate the amount of c�mpensation being sought (page two). Failure to provide information about the vehicle involved (page two). Failure to provide information abot�t the injury claimed(page two). � Failure to sign the claim form (page two). �Failure to print the name of the person who completed the claim form(page two). � ��/ � Other: � Gt�h P.�� o�.� 7�'�t�. cll"�S f/"GG li7�Gd�? 7L��2 �laC� � �� Gc�h�o �G� y`'fiL2 G�'�'t S T�u��Z�j � Please return the completed claim form to: �(���!^� � Office of the City Clerk City of Saint Paul 15 W. Kellogg Blvd. 310 City Hall ..� Saint Paul, MN 55102 If you do not return the completed claim form with the appropriate documentation or information completed, then a claim file will NOT be established and an investigation WILL NOT be done. In other words, NO FURTHER ACTION will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances.