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Binstock '3F_.._�._ .... .._ .........� - .__ j � . - - �:, ..�A� �s 20 :� - �� __ ,�. _?., r� '., . . : ,_ . .� : .. -r .. : _ .., . : - r , _. ; � � �pt! . " ; _ _: V���' _V. ',�[\f�._ . ... _ . '., . „ . . . .. . ., ..,.... ..,. -. ... . _ '. .: - . ,. . . � NOTICE 4F CLAIM FORM to the City of Saint Paul, Minnesota. . Minnesota Stau Statrfte 466:03 staus that"...every persoR...who clainar damagu frorn a�'municiPalitY--.shaU c�rse m be presaued'to the govtming body of the mwiicipality within 180 days after the allegud loss or injury is disrnvered a notice stating the tim�Place,and • ' circwnstances thereof mrd dee amount of conrpensasion or othcr relief denwnded" . _ Please complete this form in its eatirety bq cleady typing or printing your answer to each qucstion If more space is � needed,at#ach additional sheets. Piease note that you may or may not be contacted bp telephone to discuss your claim � circumstances,so provide as much information as aecessary to expIsin youc claim,and the amonnt of compensation being requested. This form must be signed,and both pages completed. If somet}ung dces.not apply,write`N/A'. SEND COMPLETED FORM AND 01'HER DOCUMENTS TO: CTTY CLERg, 15 WEST KELLOGG BLVD,290 CITY HALL,SAINT PAUL,NIN 55102 First Name S�vrt Middle Initial !m Last Name IJ b✓1 S'�-c�c,� Company or Business Name,if applicable Street Address ��3� (�P�f' aSK� --� f' .� � --- Clty�.� ��„�� S tate �N Zip Code �5 sl!9 Daytime Telephone "(�l ) 3?�- av�� Evening Telephone ( ) S'�"`'�- � Date of Accidend Injury or Date Discovered Time am/pm(circle) Please state,in detail, what occurred, and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are in olved and/or responsible. � ��.� l�1 c�;dr.�l ,aar t �a,�,� wa� ��� .� s,E� 'F��Xc n�� ►h bo. �„ks s�w Cr+�, Sno�..J �0li�,.� !�, � r+1� �rH," e�. ---�-- Please check the box(es) that most closely represent the reason for completing this form: ❑ Vehicle was damaged in an accident � Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition o�the street j�,Vehici�was-d-amaged by a plow -- ---p-�cle-wa�--wron�irHy towed-and/or tickcted _ _ fl Injure3-oz City groperty _ _ ❑ Other type of property damaDe—please specify � Other rype of injury—please specify ❑ Other type not listed—please specify In order to process your claim vou need to include coaies of all avalicable documents. This is a general guideline of what should be submitted with a claim form, but it is not atl uiclusive. You may be asked to provide additional information depending on your claim. � �Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the actual bills andlor receipts for the repairs O Towing claims: le�ble copies of any tickets issued and copies of the impound lot receipts O Other property damage: repair estimates, detailed list of dama�ed items O Injury claims: medical bills, receipts O Photographs can be provided but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form _'_ _"_-. _ . . ._ . . f.�- 1 __' _ -.. . . . : . .___ . .. . . � . . -- . . ..�.. .___ • . _ . ' . _ .' ' . . . . � . y`��t .� ^,. . ,_ ._ . . . . .�. .. . .. .. . - ' - . �... � . . . �. � . . � . . ' . � . . ... .. . . ... . . . . .RECEIVEC� � _ Notice of Claim Form, Citp of SaintPaul,page two � _ -_ ,p�.11 Ciaims—please complete this section ." . � es � � No Unl�own (circle} Were there wimesses to the incident. . . . _ - _� If yes,please provide their names,addresses an telephone numbers: Were the police or law enforcement�alled? �es No - Unknown (circle) If yes,what department or agency? a�►� �:�� �� -d�s- �3�— Case or report# i 3 - �r ' 2 �' Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,closest landmazk, etc. Please be as detailed as possible. If helpful, attach a dia�am. 8' cb . Please indicate the amou t ou are seeking in compensation from this c�aimnort�wh�f ouZ ould��e�ity� �+ t� 4�t� 2 x Yl� �( t��o e v� �o� S���-�, - � C� o"� - � qS-$ �� � � , .�3 � Hr � � �3q� ���. � �,l � ✓ rh� � — ° d � '�1� `� � � ,+r��n�sAi� '= r,lQvB?� -� �L`""`L ❑ check box if this section does not Vehicle Claims nlease comvlete this section Model —C'��ic-f.2 jy � Your Vehicle� Year Make License Plate Number State�Nt.�I Color �L��� Registered Owner ��- �%���- Driver of Vehicle � Area Damaaed s� ` Model Ciry Vehicle: Year Make License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Dama.ged - In-u Clainns- lease com lete this section ❑ check box if ttiis section does not a lv How were you injured? ti� WhaL part(s) of your body were injured? � Planning to Seek Treatment (circle) Have you sought medical oreatment? YeS (provide date(s)) When did you receive treatment? Name of Medical Provider(s): Telephone Address � � Did you miss work as a result of your injury. � (provide date(s)) When did you miss work? Name of your Employer: Telephone Address [] Check here if you are attaching more pages W this claim form. Number of additional pages • . gy signing this form,you are stating that aU informalion you have provided is true and correct to the best of yor�r 1a+owledge. Unsigned forms may not be processed Sribm�tting a false claim�an result in prosecution- 5��' x Print the�1ame of the Person who Completed this Form: g ;�L Signature of Person Making the Claim: G Revised Apri12006 Date form was completed 'y /S- /3 � . Date Shop Form No• � I , � `! � ! -s ��':> ACE TRAiLER - SALES 7480 East Hwy 101 12090 Margo Ave. So. Shako�ee, MN 55379 1-8��-225-8659 Hastings, MN 55033 ' (952)#45-7043 WWW.acetrailersales.CO (651) 438-8780 � ; , ' Phone Name `->-:-��,��. j�� �`s-� c: c �� Work '�� � . � �- Y ��� ,�; � � �� , � ,;.�—.--<�- � Address � � 3 3 j�p�U ., ��- Mobile City �� �,.,�,� State ✓1�,� Zip S�Sjlq Fax � Qty. Description Price i Mal�e Tr�„��r- Yr. _, <:.r� ��-�-., t Model 1- , ., )- ..,-;�,.;�i� ``-. ,--,. ;;�' •� y�.' `�S i_ �� � I •� � - �,n VIN - `�`` ' i ";. •, , ��,�C� =. COfOT Qsl�c.l� �� - . �i�a, �,- ��� -� /-� �_' _-,-__ ;�- .^ . 2�:., . r-� , Customer Fick up on _� Work Order * Note Special Order Parts ' � -� , � � i � . i . , �- Customer x Parts Tota) �C��-`;�- T� ��. • r. -1 ,j�- Shop x � � Labor Total `_.?�,,�� �����1.�� oftice x � Total ��"� .._(� I \ _ -------- -- � Absolute Trailer Sales 0 �n�o��e www.absolutetrailer.com [�] Quote 9601 Jefferson Trail West Inver Grove Heights, MN 55077 � - - Voice 651-454-8650 Fax 651-905-7015 E-Mail: mhallblade@absolutetrailer.com Custom r Name .�✓� DG � Date �f—��'`/.� Address Order No. City State Zip Rep �� Phone FOB Description Price � �p�C��- ��'l�/ ��'f-°��,,� .c'�"�� a�3� > ���� r,�,/��,�'��� •-7GC� - ����� ���� �30 �- �{�Z �,���/z- �-�� 95� .3. �7 �7 7� Prices Subject to Change Subtotal 1/3 Non-Refundable Deposit Required for Special Orders. Shipping & Handling Balance Due Upon Delivery. Sales Tax � 15% Re-Stocking Fee on "Like New" Returns. Lic., Title, Reg. No Returns on Electronic unless authorized TOTAL Accepted by Date Thank-You for Choosing Absolute Trailer Sales!