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Thurmond . � •�: tr�structions far Fili�g Notice of Claim ta City af �lY�I" �� �; 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_- 0��- � - k-�� G'.�(� � wr�tS o u�a�e v���..��me�� �n� � a W?n Y� tir� ���� c.�nC � ToWe� �- � C �3 r oU��l. L a+-- 3� r �e hu�r�e � � �.l S�j n —" � ��-4��1 � G� �r� r-� �y'` � Gss � � e vc��ch�S � � "1� �� �no-�i ceabl er��, �...�.�. � 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�:� ,i; �� Vehicle damaged ❑ Other injury to person (please provide specifics below) ; � �`� i� ❑ Slipped and fell on City property �� r—t � � ' � :� 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: �.. Risl< Mgmt Division - Revised 1-30-01 , I'ji;; ,����pi• ;a�,�;�':I�