McDonald, Catherine I��CEIV�D
MAR 18 2013
CITY CLERl�
NOTICE UF CLAIM FORM �o the City of Ssint P�n1,1��iineesota
IIFtNne�ora SWt SIalWe 46�QS a�alet fiot".._everv/�rao�--.rb dai�c�lo�e�csJ�'ar ary�r�nc�ty-.sWl t�Mtse b btpresa�krl b d►�
ad+���f��w�i�.laon dQy:u�er dYe a�k�rd bss or ny.w�r is�ea�vered e»oNC+e s��n.�,he tewe ploce,mad
�na�,lier+a�arl tlr a�o�t of cro�arseris�er elicr qcicf Je�r�aled"
11�M!pw�M�M�i1�"!�i�ilt aMh�b�l!�ff���e'�i�Aw 7�r a■r7�er rr Mci�e�M�a, It'a�ee�wae ic
�ccdei,attar5 a�itl�l s�ee� Pfea�e aoir tiait�w�a�t tie cr■�i Ir!tde�ir■e t�c�l[y s�vs,s rwYe as
s�i irfi��lir ac aec�T 1�eqihi 7�r�Li�a�1�a��t i a�a�ali��t re�siaL Y�A eeai�e a
vtit�ari a�da�s�rlei�uMerYt��ce�nrr�rs ir nceirai, Y1ie Mrcaac a�biAoe�1��rnel�Mr 1�ie�e���Il�
�ai�a�rr t�ba. TYc�eew�►a�o�#Le d�red,a�d Mtl�NMer�a�MMd- lt's�w�M1i�rMe�a�t a�pl�r>�reile'IITU'.
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1S WL�ST KEI.LOGG BLVD,31e C1TY HAId.,SAINT PAUL,MN SSl•2
r�N,� r,��h�Y iv�c, �aaa��wa,.��w,� ��J(��vi�.�,l c,�
Com�any or�Name
Aro You ae�noe Campany? Yes/� ff Ya,t�im N�mb�zr?
Street Adciress ���- �V� �/2CA � � �/�
Git�r � 1+ 1�11 �— � A i � S�t� �1 l�1 7ap Code.� ) fl1�-
n,�;me r�oe�(� - ca�rbm��?�1�1��E�Td�one t� -
n���a�u�,.�►�o�n��a Z f r» �� r�� � :�z ���
Pi�se srace,in detail.�occumed(hapPe�ed�aod whY�acc sab�mitmug a daim.Pfease ia�e.�hy ar how yon
se�l the G'ri�r o�f Saoiut Pa�l o�r its�iaplor��iuYdvtd�Ib�r r�far yarrr d�c.
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Pka�d�eck 1�bauc(�)t�M most ida�r te��ce�t 1�tcaaa�e�ht'�Itis� ���v l 1�v lrsc-(�t..ul �i-��.c.
�M�r vehide was da�aa�ed in aa�a�idont 0�Y����i a� �`YI�,��.
❑My vride was d�am�cd b�a polhdc ar aoadition of t�e stred O My vd�dc vvas damagod by a piow
����rc�e�ru�nno�[ial�r�o�ed a�dlar 6�ded ' 0 I�r�oc iey�r�ed oa Cit�►P�Y
�YP��PaP�'�Y�—P��fY
❑Other type of injury—Ptr�se specifp
In o�rder to pr000��your daim
Fc�r thc daims types�[od bolvw,Pieasc be 9acc w iad�dc thc doc�eols mdip�d ar it�li dehy the han�ing of
�vw c�ua. Douw�c WI[.�.,NO�I'bc�e�eried sr�i�000we t�c pnopertr af the�r. Yo�a�e asoo�n�ed Iao ioeap a
va�pyr for y�ow�tf befae��o�ar ctai�m farm.
O propecip damage claims to a ve�cie:t�a escimatrs far the rcp�s to�oar v�if the�c�coods
�500.0�ar thc aGa�i bilk sntUac�oapr�far d�trpoi�s
O To�d�oimc:le�ie cqaioc Qf�ealr tic�et�ssd a c,�py a�f Mbe ieapa�o�d k�t n�odp�
O Othcr p�opaty daaagc daiee�twro iy�ai�-tstim�tcs if tbc�c�ccooas 550�00;or thc actnal bills
a�r�oapls 6oir tie re�ai��d�od�i�t af d�a�od i�e�s
O IAjmy daims;ee�edic,al bills.noai�s
O Photo�s�ne al�vayr.wrek�ome to doo�meet asd sappoit yo�d�but will ent be ietu��
Fa�e 1 rf 2—Ple�e ca�1�1e a�i rdrt�i�tlt�x�f'G'ii Firaa
Failm�e to campkte�d n!�bati pa�e�w�7 r+es■lt a�j�tre�af�cla�.
Ap C7aiM�s—d�e a�1��
W�e there witneases to thc ineicicet? Ycs � Unlnwwn (circle)
Pt�ovide theur aawr�,7dd[esscc aad telcp600c o�obe�s:
Wexe the poliac or law enfactaement calkd? Y No Untno�vn (circie)
if�,�#rat dq�atrmant p��nc�r?L�c,�v�[.tnr G�#or rc�o�t# aJ��d "1�j�'�.ol io
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ti1V�a+e did tl�e aoc3deet oc iujiuy tai�e plaoe? Ptuvide stc�eet ad�ess,aoss street,iatusedion,nac+ae of Park ar facelity,
clasest bon�n�a�k,duc. I'Iczsc bc aas debiiod�poss�ic. If nioassaryr.a�a di�r�m.
2►-,�, C t� A-11��,�-��c
Pl�se in�ic�te the amoant you are seeking in connpe�0ion a�whaR yau woold like the C'�ty to do w resolve this daim
co y�our�aatii�an, -�inc� Gv t � c,uw��rn�n-t ,���ca! �v �t I�cw 1 Pv l ��.e,
Vin t7�UYi�' � R
Vdiidc(�i�s ekasc�e tlis scc�e� �c6eck bo��if this seaion dces not a�uaiv
Yae�r Ve�+icl� Yeu � ��
I�oons�e I'la�0e Aluiober Sh�e Co1or
Registe�ed Oarner
Driver af Vdiido
Area Dama�gec�
C�r Yehic� Ypr � MO�
I.�xo�e Pl�e A�mobe,r StsAe C.olor
�riv�ar of V�(C"aA7 E�loy'oc's Nauoe)
Arta Dama�ed
I■imrr G7Y�r�t �_ '��u•• ��ax if itic s�ectiaa das�t�Y
How w�r�e yon injw�ed?
W�it p�t(s)of l�'��'m9�od`!
Have yon saagM medical tr+e�meat`! Yes No Pf�to See�c Treatme�(cirde)
Whaa did�t�occi�e t�alae�art? (p��d��))
Naim�of Modic�l Pravid�a{s�° �
Acldcess T
Did�oa mi��nod�aec a�ns�af�o�r� Yes N°
Wlraa dd�rora miss wrat`! (P�'ovide date(s))
Name of�F.m�lqer T�
Addrr�
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