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Smalley : : RECEIVED APR 03 2013 NOTICE OF CLAIM FORM to the City of Saint �.TTY ����� Minnesota State Statute 466.05 states that"_..every person...whn claims damages from any murticipatity...shall cause to be presented to the governing bndy qf the rnunicipality within 180 days a/3er the alleged Inss nr injury is discovered a nntice stating the time,place,and circumstances thereof,and t&e amount nf'compertsarion or other relief'demanded." Please complete 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 sometliing does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL, MN 55102 First Name ��L Middle Initial � Last Name s�'t Q / Company or Business Name Are You an Insurance Company? Ye /No Yes,Claim Number? Street Address � �?!Z- .�/`Q D�[� �i`��G City �05�v%Il2 State �� Zip Code ��ll-� Daytime Phone(b� .�b,�326 2Cell Phone(� ���e Evening Telephone{^�4'�e Date of Accidend Injury or Date Discovered�y�3 Time y% 3� 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 Saint Paul or its employees are involved and/ar responsible for your damages_�(J/i�'�� G/� o�t•� l�u4 y `�z� ��fG Q�w/b/f' �`i-cw� a��tr LJo�it /k r•se�ii/l�' INc� Guif� P�d `1 if S �— e G holc ' ' ` `�� . /y .�- i / o — ve�d ` S r d �t. W 5 %+ �•�[_ ` 5 . r Ost `i lt 6GO ��.�g p�1_,�.:� . i3 ts,L Ov�« E.v� -,(�ouH Gva 5 �/7'2,`� .otr ,L`,���.ca �c/a GL f,l��,� �� �5�_sQ��-Y-�YIr,(j��ii�.i� �R�/.G L'Nn.� /Ht/dl�� .. � ` Please check the box(es)that most closely represent the reason far completing this form. ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow �Sf 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 ❑Other type of injury—please specify In order to process your claim vou need to include copies of all applicable documents. I 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 far yourself before submitting your claim form. ' �Property damage claimc to a vehicle: two e.ctimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bi1Ls and/or receipts for the repairs O Towing claims_legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims:two repair estimates if the damage exceeds$S00_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 be returned. Page 1 of 2—Ptease complete and return both pages of Claim Form Failure to complete and return both pages will resuit in delay in the handling of your claim. All Claims-nlease rnmalete 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 facility, � closest landmark,etc. Please be as detailed as possible. If necessary,att�h a diagram.�.�`L�/r�c�/ v�_�m�`��' S�uf�, b�uh� �� so . soK� s � Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. +�L,�/4 sa ,�-s.- T��'1 S 6 a/v�,c w�--d a��i.oa / Vehicle Claims- ea9e c�o lete this section ❑check box if this section does not a 1 Your Vehicle: Year a�!a. Make Model C C License Plate Number $S 9- /-f C/� State M�l/ Color re4 Registered Owner h le .T. ��a Ne Driver of Vehicle s�4'/ Area Damaged �o�i ry 4hf- �'id� �'�,�Ps City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims alease comDlete t1�is section ❑check box if this section does not anplv 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 your 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 staling thut all information you have provided is true and correct to the best of your knowledge. Unsigned forms wiU not be processed. SuBmitting a false claim can result in prosecution. Date form was completed 3 l3/ � 3 Print the Name of the Person who Completed this Form: � -�/�- ��Q 1��7 - Signature of Person Mal�og the Claim: Revised February 2011 __ L�N � �'� � o �,u � T � � , � � ,� r i � . 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