Nelson - �;��� � ,
� MAY 08 2���
NOTIC� OF CLAIM rORM to the City of 5����;����lesota
Mimtesota S�u7e Stcuute 4CG.05,ctuies�hat "...erer��person...�+�{ro cl�ims dumagec fi�orn cun�n�u��icipulilv....chnll cc�use to be pre.c�-nted�o thc�
�oi�ernii��bnd��o/�lhe muniripa/il1'�vrlhi�� 780 claps n(tei�die cil/eged lo,ss nr inji�r��i.c disennc�red a nolicr�,statin���{�e tin��,p/uce.a�id
circumsturaces thereo/;und�he u���ounl o/compensalion a�oIlter rr�lierdemunded."
Please complete this fonn in its entirety Uy clearly typing or printin�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 infonnation as necessary to explain your claim,and the amount of compensalion being requested. Yo�will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature or yo�r claim. This form nmst be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 W�ST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
James E. &
First Name Rayanne K. Middle Initia] Last Name Nelson
Company or Business Name Minnesota DOT (James)
Are You an Insurance Company? Yes�If Yes,Claim Number?
Street Address 5513 Portland Avenue
City Minneapolis State M� Zip Code 55417-2442
Daytime Phone( 651� 23�'7605 Cell Phone ( ) - Evening Telephone(612) 823-7433
Date of AccidenU Injury or Date Discovered Apri.l 16, 2013 Time 1•�� �arriy pm
Please state,in detail,what occuned(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/or responsible for your damages. Vehicle was
damaged by a verv lar e�pothole (+� "x �� "x � "D) in the street; front tire was
shredded; replaced damaged tire with a used tire; mechanic discovered front wheel
bearing is also damaged which requires replacement (Note: wheel bearin� was fine
when vehicle was serviced on 3/28/13); damaged tire is available for viewing. Enclosed
are 6 photos & Apple Valley Car Clinic invoice & estimate.
Please check the box(es)that most closely represent the reason for completing this forn1:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�] 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 you need to include copies of all applicable documents.
For the claims types]isted 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 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: ]egible copies of any ticket issued and a copy of the impound]ot receipt
O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actua] bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: �nedical 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
i
. ` -�
.<<.� � -� � �
� 't;.:�� i • � . °;°t,
I `• �
I
I
� � �,
i
� ..
�
. � � � ��. _.. -_�-...: - . . . . �,_ '.:.�;.-� � ....� :� � � ,A�:.�.i �x..: ':c,�_ .
. . . _ . �.. _ .. .. ._... ... .. - � _. `� � . _° .
" '. � . _� . . ... .: . .. . . .. . . � . __. . . _•. C . . . -
. �
. Jemes E. & Rayanne K. Nelson Vehicie Damage Claim
I+'ailure to complete and return both pages will result in delay in the handling of your clai�n.
All Claims—t�lease complete this section
Were tl�ere witnesses to the incident? Yes No ��own (circle)
Provide�heir names,addresses and telephone numbers: N/A �
Were the police or law enforcement called? Yes � Unlcnown (circle)
If yes, what department or agency? N�A Case#or report# N/A
Where did the accident or injury take plar_e? Provide street address,cross sh�eet, intersection,na►ne of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diabram.
1810 Ford Parkway - East bound lane
Please indicate the amount you are seeking_�compensation or what you would like Che City to do to resolve this claim
to your satisfaction. $474.43 Total (�58.44 for tire replacement + $415.99 for wheel
bearing replacement) - See enclosed Apple Valley Car Clinic invoicP £� Fctim�e
Vehicle Claims—ulease complete this section ❑ check box if this section does not apply
Youi-Veliicle: Year 1994 Make Cadillac Model E1 Dorado
License Plate Number � State MN Color White
Registered Owner Rayanne Kohler Nelson
Driver of Vehicle James Edwin Nelson (S�ouse of Registered Owner)
Area Dama�ed Front r;rP £� wheel bearing
City Vehicle: Year N�a Make N�A Model N/A
License Plate Nwnber N�A State N/A Co]oT� N/A
Driver of Vehicle(City Employee's Name) N/A
Area Damaged N/A
In'ur � Claims— lease com lete this section L�check box if this section does not apply �
How were you injured? N A
What part(s) of your body were injured? N/A
Have you sought medica] treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? N/A (provide date(s))
Name of Medical Provider(s): N/A
Address NzA Telephone N/A
Did you miss work as a result of your injury? Yes No
When did you miss work? N/A (provide date(s))
Name of your Employer: N/A
Address N/A Telephone N/A
� Check here if you are attaching more pages to this claim form. Number of additional pages�f 6 Photos.
By sig�zi�ig tlzis form,you� are statirag tlaat all i�zfor»iation you Iiave provided is true and correct to tlie best
of your k�zowledge. Unsigized for�ns will not be processed.
Sub�nitti�zg a false clainz can result iiz prosecution. Date form was con�pleted May 2, 2013
Print the Name of the Person who Compl is Form: Rayanne K. Nelson
t �
Signature of Person Making the Claim: f
Revised February 201 I � �; ������ �.-
�� .s��",,�
I
. . - '_�
�
i
I
I
_ .
_ . -- _ . . • , ._ .. : _ _. . -' - _ .>„<� �.�_� .��.;:,�,� , . _ . _.
%j ,.
- - - - -�a�'
� � � " ' � i�
� . . r� � c�o � � c�o _ o o ��'• �.
�A o � o r � N o r . . �� �W � o 0 o ONi O�i I a�o �i �
• �'� � � oi '- �� � p � � � �n � . Z� �i � M M N I t�A N lA
� Q� p ,7 0 �. V' w�� u
p0 O � ��. � �'WW 3� ,
a Q=� i
• M Z ni E , di E ' v�O U =i !
�' v E �° � � E -°o 0 0 �cna �
------ c_~ O � i= O o � a w� �I o � °> m e° ' :° m _I
� l' M Q� �! J a (j d u�) I 3 F 0
w I i � � F-
� � -- -- --------------- -- �� � �
� � i
�,
d ---- ------=------------ --'-- ---- ---- —�-
-----._—
Q1
f0
a
o ; �
U `°
0 0 � ,
Z � -� `°
N � � `�
J � Z I W N� � �1\
U � � �
�, � � �� ; �
�1/ � �' - cu.ic� ; z
QLL �
G J fC ('�N � �
O Q N U � .-> � o
v •• ;;
o > � rn 2;� � � N cn a cn
� Q J N � > >a ' cv �• c.w7 .wa �
------- ------- ------------ m �C w FC
W Y a v 1 o a e. w
I
0
_1 � � � o � o � o _�
J c a� o o� a a oaa E
Q ; � N �..� a � � � 2 � � �
> 0 = I � 'i � � � cz w 3 z [�.., � x ,
� �� � j � . N x � Oa � o�., � a � 0
W � a E-� c0 w H O � rx H W E-�
� � O `r .,�. Z C � x FC 3 £ 2 U C] E x 3 2 \
� ' � � ' • � 'N 3a00c� rZC4 H030cxn:
� I I �-1 H W W W q H I �7 W W
/1 I� ti � C� � i--� X r7 .] UI E 5 x tn X .�7 E s V
LL � a . ,��7 ++ 0 W r� W :7 Z i-��E W � G] W Z E-� I
� Gl � >+ U H O O c4 U o .>+ H O C]
� � rx W 7 � I I I I I I I 3 I I I I a
� a o
a Z � . F � �,
� �� � ' • w °� �
• u� w ro --- _ ------------ -----------.
•- �= � o w .,� -
W i O ,,, U �
p ZZ � m m oo a� o
Z Q�a y �' >,
y �Q M � N i � � Q' N Cn .
U W}a- C � . �o C t o �. N
Q Z�u�� 2 � a� .� �,='r E °�
;� F � c� a� � �,w
t c c
a`� � a� '. � m m
o O o �� � o c.0 �� o � o
0 o O oC � n3c
. , i �� m � �D N
ri E `o d
� � i a d '^ . °-'�da
i a�i 3 L �. '. � �, � E a�
L
�+ � _ � T�
� a.y p j � l0 T
—-'"" —"—_—'__ _ - —_.__._.____"_ _.__"__—- _- ___'_._.- - . ._ __-_—___ U .
� m � y d�N
� � N
L1 4L W ' I T a��� m N � �c-S ti
L,`' 0.'i C1.' . I �N� v � 3 j� p
i/� Cn Cn I c'V y N - �, C�_
___'._ —'-__'_.-___-"_-_. _. _ .._.
'__- __. .._-._______ .-___ m
__..._ ... _-_-._..._. .___ '-
� � m o p - ��� U E�a�
r �o c m _._- �'E c
� � � E ar c°� c �� o w
�� �:,-i .7 i °� a�i� �, c � . �Ni?
� n o 'a n�n
. W £ I W E a� �o � .. p ', � uxi `°
_: � cn I .'x y Q a ai � � � z o vL�
�+ (n I s N� Z '� � L" �a
'� � W O � I 2 a�i�`- a� � � °� o � m ��a
J !Z c� W i � � E o � N � �a, ^' '�� 3 , �'� m�
~ O F F � i C� .3� cL � . n o . d� NN
O :z Q cfl � I Zrn rnZ`-a t° � � a � �' tm °o
W � i--i rn o � � � °, m -� a 3°m
cZ W N 2 cn fx � � .
cn FC U1 FC Z FC �n 1O-°10 � m c � 01 E m a°m a u`°i
E-� U � W O W ,� c o o ° E � � `� , m � E�t
Z h-lt7 H [Uv� o _ � c � a � > >�
� H � O Z F+ �r `0.
3 ,'� x H � �l a.o�D � c°' n' .., N o" n3
O W E+ fx O W �7 c' �n u ? �i , � . °'�. o
O C� O FC Z W us ° n.� m � � �� � � w �
• Z, Y. 2 W W W x W �6.� � c � ,� D �., L �'o i�
FCU �C a1 � 3
G] �7 F E-a 3 m�� c � c E c� . ° n�c
u � � i--� E-� �OE-� tn °' co � L E 3 a� �. a � °' axi.�c, c�
� U CY� x 2 U �Z W ��c�c` . ... a c � d �. �c �_ �
r-i O W O H-- �0 1° d d '° ,� m� �
E-� C] W G1 E-� fx C4 0.,' �+ o`o E N � �� c c°�i c �' � � � o�
a a z a w �., a ,� - �o o � tO
3 L=a
Ll FC O FC O W W y m u .` - n 3 c a m
x cii U c/1 z� �0 0�.c � d d o . � �a�•-
� :� C�1 E" TL � H C] W a�-�� _, . Q m � �, � . ¢� c�
C.S F Z U W :� W ul � � d a� o o,. � 10 m
ry� � a�i O xZ W Z �C to �� � a � ° o �rc�S
'a � U � -
~ � N �i o zaE°
' � � ���
; .�' ��,, �.
� �� � VU
� � • ,� o
. � I •` - � (�� �
4�� � �_ � � ���.�
.� ,�. . ,��-.
�, � -_ =' � .
_ , > �
,...y . \,_ /�
. �• �*�� � 'y f� � ' i y
.. a.� . . .f `;.
�-�� � -
. �-�� . . . �+�� '� � `\
; ���
��� . . .�: . �;!, , t �-.
.
�ti `, �'~ '�r . " ,'y'. ;`. ���C
` • . �7► . ' • �� _ � . •` ��.s, -���
� r . , ..� .,�`,r'- L � 1_.. ,�sr� �' �fi
`;, � ,, . • .j t.� � � ,,� � .. � ; , �,, J�
' . -: • ' � - ,� ; • �Sar � ; w ,� \ .
;T' a,'yr . � .l;� r�i� T, �'{'�. � i � \.?
•�,��;f�yr_��V " i i„ .�.! •� *�F ����� -0
. �•�'_�R p►l�fiT..''�.vf:_'..� i�+.���•.'. •���.. w{��Jc'T1 � ��' .�,.�• � � t _ '}��\.
��4�
llii ; 1 I
'' ! 1 IiIIID
/!"' - - !' ,,.� s ��""".. ,�
��y„� �� `Viii,,l l �
_,�...�►- � �-..r_ r
�1/�'"..� �
�:�t
_ �� • _'_ �
` ..,.�
� ° -� `
,
�. ' �
_ •�'
� �.x -
� --*- _ ' �^ „'��";��'� -�. ''""."'_._- , ' F J �\
__� " «r* - -. ° ' �' r' \��
�� �
;' „ _
� t �_ �"'
� �_�W
- � \. r-
- . ', - �� ' �r, .,�� ,�� �7
,•
, '' :-
: • ,;� ,
_�,
<
,,.` - �'�• 4'
�y � i�:, : r--�
_y'��` . , '� � � ��, �.y;�
• �' .+, �� ''�� • f�� �' �;'` . ^� .���\ ,
•���� ' ��f"$ �Y � �.� ��� � � . 1\ l
.�A � _ ;��g ��:�r. f� .�r.,-. �r Y. A .
���"�t�`_ y'` �s�Y �
�•'#�-�� '��, �
rt �,� �
�`r'; ; �, v, �.
i �ii � � i
,�
'�� I 1 IIIIID
�
�*A--� . .
� ' . . ���'"�" , ,b
. . _..�•�.�.�� ../ 9" � �"'�� •� '`'- �
� ,. ,
- .�.� 4 .. . " -_- • j~ �
` -�t-_'s,.-. � � s`P \
'�►._ `. • ,;:;:;. -""`:'���"- _. -`�%"`.,.""`_ _ �
_ -� - � � ^� `
.rs • ��� _ �� �,,��. ��
. •_�at ' :�_ `rA �'� "�'�~�G�,
, • •
,
r�`,'�` } r..�`.� , �. . __ � �'"� ._
� � ,1���'- .-��. -_�� . . , � _
_1:.�,d_ � •f�''�• . . - � " �. -
� . _. ,.,. -•. #t- �
y� ; � E . -.t.� , _ �
'���'�,�r .,.-s+yiy��„rsl �•���J. . . _l�'_}. .. . .- J��*+,� '{� -„ �
�.
, .
�w � � �; .i� r a { � J r
F. �yE1, r.� � .� �` �� s'��� - �'- "ar t� "�- �'�'Z'
s
r :.. �•'� -� . .�i,,�1 � ^ ��/'� �r�.. �` .§f"d"!�!' - d �R
'�s �'r`rjf�`yF•.�'_¢,�.� � - j ' 7��yy�"-t „Y�' .
,ai�«��� !�� � '� ' . ,_' e.•�"_'9Y ' .�
��r�,� _.€�'�l _ � �:•f Y� �+ :�'' • �V,
',:a.�`'�'` . �4 . ��� .�����
� _;��yI�' '` �
�. . - �_y�
. J'+�� ,f�" -.... _;,:. �:;- .,,.:
� s F+•X.," . � �
.. . `."�w,�P e,.,�s,�..�
J
� �fi� o i
�
�
� ,
���, � � i ��ii �:.
� _ '. : .. a.._. , '.��
� � �
:�' � �
� �-S�y
�
.
',�,
�T�� �, �
.., �--� �
, 1 _ �� ;�
� , �. ,�
� ♦ _ �
,� .�r���. ,.�► .,..�
�� �.�, �- '' ��•e �1 �, �
�.�
� � � �: �''�' _ �.� � �i' ���� -� �
__ � ��/ {'
�. . ��' "i �'► ������ , �+ . �. ' r fi�
, , - � , ,��1��
� • � ' �-��\
. j�, _ , r � �
f�I�T � ' � • �- �` "�-
t � ,
� -�, , • <<. . � ' .'+` J �.
� ii;; �r �� � � � , , ,. j -�.
.^''� •- ►` �4 1 ' 'e� '�i`'V� .�6 , � � W
, -► ,?'� �= .. .�k y ^# � �L
. . , �3�1t� �` ' ��
. _ � �:>.� <'y
i �ii � � � i
' � 1 IIiIID
�. � - . ..� �
� -- �� .
..._._ i � ' -�. v
- '�� � �"`�J
�`' , � .�
_ � �
. �.
, ��I J��
• �,�
•'}c , '� y � � �
•��� - .. .� . � �,,� , �* { �
. i � . - � ,d.� •� ~� `��
r i ! � _ -�
. . ' . . �,
'�f M �, �1.' -���. � * � ' `�\�
`���
. �i y � �-��� ��
.;' '',a-: ~���'�
:�r'���' � . , � ` �' �
, � t : _ - ��I�� t; , _' � � .'�,,�:, �' � . .v
.._•.►. ,�r �� �� c�.f-:�� � a +�t.�►a i��� e ..�
ii�i � � �
''�� � � iii�i :,�
�
_i _
-� � w��'u c -
�. _ ( � . � \ ,��''�� .. .+�� �
� y �, �� ��
.� ' '�''���...)
��� ���
-�- � 1 (tis �.
�=�� `(�°r- �r
- '�.':. { p �-� �i
�
. .:'. ' ` ' � '�'
. - ... � r^� ��-,
+ .•,� :
.
\7;� t -. .,.,s.. ..
ix
� � "� ���{. .. ��
� +L _ .a. -� �
_ ��� , � �
• � • �"{�7[. r���.
� ' . ' ��� ��
r .
4 � Y'�. ��o
L� �� '�
, �
�.'.
i �iic t �
� � iiiii �;