Thurmond . � •�:
tr�structions far Fili�g Notice of Claim ta City af �lY�I" ��
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lt4innesota State Statute'466.05 NOTICE OF CLAIM...(E)very person...who claims damage3►�I�oM`�n�013
municipality...shall cause to be presented to the goveming body of the municipality wiThin 1$L, a s��r the . �
alleged loss or injury rs discove�ed a notice stating the time, place, and circumstances ther�dt� ���i'e amount of
compensation or other relief demanded.
Please complete ti�is 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.
PLEASE RETURN �!THIS Office of City Clerk
COMPLETED FORM TO: 170 City Hall
15 W 1<ellogg Slvd
St Paul MN 55102
Your Name: ��1J')'..i F�r � - T�1 l.t v►N�O►'��
- _ Street Address: -- _(� :�(p- �j-t ��h���- ���IJL��---�--l-E`4� __ _ _- - --___-- _ ---_ ___-..----
City: ljT ���-�-- State: ("l� Zip Code: �� � �S
Daytime Telephone: 16�I 1 ���O�!�� Evening Telephone: _ �Iv�l) aO U �"��� �
Darte of Accident or Incident: �� l.3 �Day of Weelc: �r�ot Time: �am r pm (circle one) ,
1.' wee1� oZ txn 'l /�lLl.. ,
Please state, in detail, wliat occurred and the circumstances surrounding the event. Indicate how the
City of Saint Paul is involved, and why you feel the City is responsible.
� - Q�D�- �-aa—�3 0� S,�o�,c� ,� e wc� c�I1 e at i � ST, PF�u C_-
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� G�Qr s s�ec( cc;��er� +v cz-t'te� �-�^k-�,� a�u iwho �� \ +rne t� �jo 1��i� �Ff�c e a�� i
Please indicate your reason for completing this form: V'cv�eS�1" ��1t5 -�Or►^n �
L.:l Veliicle accident 1--7 Other property damage (please provide specifics below) ;;:;i'I>
� Vehicle was towed N� �- :i�:�
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�� Vehicle damaged ❑ Other injury to person (please provide specifics below) ; �
�`� i�
❑ Slipped and fell on City property �� r—t � � '
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Please provide tf�e names and telephone numbers of any City employees involved in this
incident/accident and iiow tfiey were involved: � ;
,
,
�
(over)
. �
If your vei�icle was involved, please complete the following;
Year, malce, and modei: License Plate Number:
Extent and area damaged: {,���N�(� bu rv�„� r — aa ss��.�er s�d e
Was a City vehicle invo�d in this accident/incident? Yes No (circle one) --Te�� C�'rn�`��
�
If yes, please complete tf�e following: Type of vehicle
Year, make, and model
Color of vehicle License Plate Number: -
Description of vef�icle
Location of accident/incident (piease provide specifics sucl� as street address, intersection, cross streets,
park name, facility name; etc.):
Please draw_or_attach_a diagram if_a�pli_cable;
Please 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 veliicle, please submit two estimates.
Were there 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 compteting this form:
Please si�n your name: e
(
Date form signed:
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Risl< Mgmt Division - Revised 1-30-01 , I'ji;;
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