Rysgaard � � RECEIVED
ppR 2 3 2013
NOTICE OF CLAIM FORM to the City of SCIT`���esota
Minnesota State Statute 466.05 states that"...every persov�...who cbi»ss damages from any municipafity...$)ratl cause W be presented to the
governing bady of the municipality within 1&J days afttr the aUeged loss or injury is discovered a naice stating the ti»ee,ptoce,arrd
circwnrtances thereof,and the mrwc�nt of com�ensatinn or other relief demanded."
Please complete this form in its entirety by cleariy typing or printing your answer to each question. If more space�
needed,attach additiona!sheets. Please note that you will not be contacted by tetepho�to clarify answers,so provide as
much information as nec�sary to explain yair daim,and the amount of compensation being requested. Yon will receive a
written acknowledgement once yoar form is received. 17►e proo�s csn take ap to ten weeks or longer dependiag on the
natnre of your claum. 17iis form mast be signed,and both pages completed. If somethmg dces not aPPiY�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 �c'1���- Middle Initial�Last Name .� �C•r'���Q
Company or Business Name � '��✓ �' '���'� ����`�����
Are You an Insurance Company? Yes/N� ff Yes,Claim Number?
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Street Address �3� ��-�o�-L���-. R��J�
city� �'Q��S Q�tL�.. state M t ►�IJ�t S cT`Tl� zip Code;�22
Daytime Phone�).���Cell Pho�(1Ya.����Evening Telephone c 76B)�-5����{
Date of Accidend Injury or Date Discovered �"�9'� Time l+ 3� an►�pm
Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how yQu
feel the City of Saint Paul or its employees are involved and/or responsible for your damages• i �
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Please check the box(es)that most closely represent the reason for com letin this form:
O My ve}ucle was damaged in an accident P ❑My vehicle was damaged during a tow�
'�M vehicle was dama ed b a thole or condition of ❑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 You need to include conies of all aonlicable documents•
For the claims types listeci below,please be sure to incl�de the documents indicated or it will delay the handling of
your claim. Documents wIL I-NOT be return�and be�come tt►e PropertY of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
•property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage excceds
$Spp,pp;or the actual biils andlor receipts for the repairs '
e Towing claims:legible copies of any ticket issued and a copy of the impound lot receipi
O Other property damage claims:two repair estimates if the ciamage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims:medical bilis,receipts
O Photogaphs are always welcorr�e to docu�nt and support your claim but will not be returned.
Page 1 of 2-Please completc and r�.urn both pages of Claim Form
Failure to complete and return both pages will resuit in delay in the handling of your claim.
All Clauns-ulease comulete tLis section
Were there witnesses to the incident? Yes No Unlmown (circle}
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what departtnent or agency? Case#or report#
Where did the�ccident 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,attach a diagram. '���'r'iw] F����-
S 2 q'� ai-Q ���D .
s'�'� iW�-�`'►�'�
Please indicate the amount you aze seeking in compensaUon or what you would like the City to do to resol e this cl 'm .
to ow sadsfaction. �:��_�� � 1�l('r �S �T�1'� '�ZSQti4't�C'd'��'Cl�'T{A�., �=�E��1�c'
' L'1�'1�E d� �t��. �css�i"S �,�.s�cc:��.+0
Vehicle Clsims o1�se comulete this section ❑check box if this section dces not a��
Your Vehicle: Year �dd� Make ��10 '1 Model � �'�'�`�ti��-
License Plate Number Z2l 0 I�X__ State M Color 1.1�
Registered Owner�,���-'�' PrL�iN�1 �I�G-!4'°►�-t�
Driver of Vehicle �)�.�- �'�-�--R�''-������ �— -
Area Damaged ^ � ' � /�
\ 2_.-_..�_..."'___......_. . fY. .���/'��
City Vehicle: " —
License Plate Number � State.��Col �'
Driver of Vehicle(City Employee's Name)
Area Damaged
��_ ��� ����n check box if this sedion does not 1
How were you injured? ` � -
What pazt(s)of your body were injw�ed? 1-c+�+�.i--.- �A�rl�-�-
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treaUnent? ��' '� , (provi�date(s))
Name of Medicat Provider(s): P�F_e�'��-�k'4'�f� ' � �K.► (��c44�`e �B lC.F��-
Address '3��(, S.�. V �. u Telephone f���..- :��""i1r�' —
Did you miss work as a result of your injury? Yes ' o
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�Check here if you are attaching more pages to diis claim form. Number of additional pages�
By signing this form,you are stati►eg that all in,formation you have provided is true and correct to the best
of your know�edge. Unsigned forms will not be pmcessed.
Submitting a false claim can result in prosecution. Date form was completed � `��r�''��
Print the Name of the Person who Completed this Form: ��i �S 6-�
Signature of Person Maldng the Claim:
Revised February 2011