Guild NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality 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 acl�nowledgement once your form is received. The process can take up to ten weelzs or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something 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 � t� Middle Initial ��`Last Narrie� V ,� l.A/ R E C E I V E D
Company or Business Name ppR 3 0 2013
Are You an Insurance Company? Yes/�V� If yes,Claim Number? CITY CLERK
Street Address��s� � �;�°`'�����
City '��� ���L State �1v Zip Code ����
Daytime Phone�����L�Cell Phone�)�-��Evening Telephone( ) -
Date of Accidend Injury or Date Discovered Time '�� am/�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fee the City of Saint aul or its employees are involve and/or res o sible for our damages.
— �� �
,
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Please check 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
�y 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 s�cify
❑ Other type of injury–please specify
In order to process your claim vou need to include copies of all applicable dceuments.
For the claims types listed below,please be sure to include the documents indicated ar 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 for yourself before submitting your claim form.
O Property damage claims to a vehicle: 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 claims: 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 witnesses to the incident? Yes �_�,' Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersecti ame f park or acility,
�closest 1 n�d�m�a�r�k,etc.f�lease b a d,gtailed as possible. .If necessary,attach a diagram.
a��b�,�1�1�1 M �-. � ,(',W /�
Please indicate the amount you are seekin in com nsation or what you would like the City to do to resolve this claim
to your satisfaction. ►1 i
Vehicle Claims— lease com lete this sec 'on �check box if this section does not a 1
Your Vehicle: Year�,�Make Model
License Plate Number �Stat Color _
Registered Owner / �
Driver of Vehicle !° v �
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease complete this section ❑ check box if this section does not applv
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
�C�heck here if you are attaching more pages to this claim form. Number of additional pages
�
B��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
Print the Name of the Person who Completed thi Form: G l�
Signature of Person Making the Claim: r
Revised February 2011
MR. TIRE SERVICE Repair order#$039713
1201 RICf STREET Date : 3/18/13
ST PAUL, MN 55117 Page : 1
651-487-2851 Center : 1
Customer: GUILD, ALICIA Vehicle : 2003 DODG NEON
Address : 835 COMO AVE#27 License : UDA250 Unit :
City: SAINT PAUL, MN 55103 VIN : 1B3ES56C73D128216
Phone 1 : ( 651 ) 239-5473 Ext : Engine : Trans :
Phone 2 : ( 612 ) - Ext: Mileage : 143316 Colr :
Op Tech Description Labor Parts Subtotal
Quan Part Number Part Description Reason for Replacement Price
TI1001 RPC MOUNT & BALANCE ONE TIRE 10.00 106.49 116.49
-INSTALLED ON PASSENGER FRONT
1.G0 356302413 185/65R15 KLY EXPLOR 100.00
1.00 TIRS FEE 3.SC
2.00 WW WHEEL WEIGHTS
1.00 SC1212 VALVE STEM 2.99
Discoun 0•00 -20.00 -20.00
OK Bad Recommendation OK B' � �dation OK Bad Recommendation
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I hereby authorize the rep-
necessary parts Labor: $10.00
ssion to operate Parts : $82.99
and materials and hereby _ SUbI@t: $O.00
the vehicle herein describe
at your des-
cretion, for the purpose of
s mechanics OtherFees : $3.50
..e amount of re- SUpplieS $Z.00
lien is hereby acknowledged o. Subtotal : $98.49
asponsible for delay or
pairs thereto. Z understand t� Sales Tax : $6.33
other consequence due to the uno �s shipments beyond their
control. Not sesponsible for dam �es left in car in case of fire,
Paid ey: Total : $104.82
theft or any other cause beyond ou: _rol. MSTR CHARG VISA
WARRANTY IS 90 DAYS OR 3000 MILES WhZCH EVER OCCURS FZRST, UNLESS SPECIFIED pay Ref: Paid : $104.82
OTHERWISE! DU@ : $O OO
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