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King RECEIVED APR 2 9 2D13 NOTICE OF CLAIM FORM to the City of Saint��l���ta Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented ta the governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation 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 boW pages completed. If something does not apply,write`NIA'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,MN 55102 r First Name �'��Sl/� Middle Initial Last Name� Y1 Company or Business Name Are You an Insurance Company? Yes No If Yes,Claim Number? Street Address ��q� ��bu �,,� City • 'f � ��U�. State �N Zip Code 5�` � Daytime Phone(I,�_)'��2 -q�Cell Phone(�)�2 p S9 b Evening Telephone(L )�-� Date of Accident/Injury or Date Discovered�� � �1 � Time r^�am pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you el the City of Saint Paul or its e ployees are invo ved and/or responsible for your damages.`S vV�f`�-� Tr�d�i'' ' C1C� �l► � tl cCt � Z . O - , ` . � , � " " G G � � e � �� he d 'd �� , t Y1 'vV�s �� S' � �n� 6� 5 5 ; �e ' v� �l i cc r 6V1 . �, r� . �m a � a 5 �k he 5�: dC�`�G '�L Pl ase cfieck the box(es)that most closely represent the reason for completing this form: _ ` My vehicle was damaged in an accident ❑My vehicle was damaged during a tow �� My vehicle was damaged by a pothole ar 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 auplieable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your daim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vetucle: two estimates for the repairs to your vehicle if the damage exceeds $500.00; or the actual bills 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$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury daims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease comnlete this section Were there wimesses to the incident? Yes N Unkn wn (circle) Provide their names, addresses and telephone numbers: �C',C� °— Ca� • � � .' `f � i�� 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,intersec ' n,name of park or facility, closest landmark,etc. Piease be as detaile as possible� If necessary,attach a diagram. a'V�5 � P,� `C 'I Oc� � —G • Please indicate the amount you are seekin in compensation or what you would ike the City to do to resolve this claim to your satisfaction. 3 gz�K-� � � � S 1 � � , i Velucle Claims— lease com lete this sectio ❑ check box if this section does not a 1 Your Vehicle: Year Make Model License Plate Number 4t�^• �/ State� Color�,� Registered Owner Driver of Vehicle Area Damaged � r City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—please complete this section ❑ check box if this section does not anvly 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 stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �12�1'I�J Print the Name of the Person who Completed this F : �t ` n Signature of Person Making the Claim: Revised February 201 l � I }-',' � - " \ • � A. r ' � . � ?�� : i ' : � .., - �I �' : ;i►' ��::r �lo."y, '� - ;�� .yf ►� � �� ��_ #�'"`� v�:. � i ;.. ��?�;s. ..�.�r � �'�' `'.-",�},,�.�"g�'.°�g, t r':: �'�-. :c� - '.zr h� .. a � � : 1 c , a �; � � I i 3 �,, f d .e � � F�t �'�a� * �� _ � t, .� �J � � r ' ��,,, �° � ; . �� - �^ r� , �,� E �,� - - . - ,� � � � ` � ° : � � =�� , � �s��� ' F , .q� �s . v�'v � � . . � �� ... 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