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Bund RECEtVED NOTICE OF CLAIM FORM to the City of Saint Paul, l��s�� Minnesota State Statrue 466.05 states that"...every person...who claims damages fron:any rn��nicipnlin�...s e to e presented to the governrng body of the rnunicipality wrdiin 180 days after the alleged loss or injriry is discovered a notice� 'r g ie��id crrcrnnstances 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 ctarify answers,so provide as much information as necessary to exptain your ctaim,and the amount of compensation being requested. You will receive a written acknowledge�nt 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 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 !'� �r4�� 15o N Middle Initial Last Name �� +�.1 iV L'�} Company or Business Name �r� � 1� Are You an Insurance Company? Ye o� If Yes,Claim Number? Street Address 3��f`' 6 1}� �L`C �i Cit S C-'U�.� � 1� ,' • y � $ t�t U L- State 1 �+�� - Zip Code �_� �7s� ,. Daytime Phone( ) - Cell Phone(65 1)��-�Evening Telephone( ) - Date of Accident/Injury or Date Discovered � � ( � �� Time �-�L� am/pm Please state,in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you feel the Cit of Saint P ul or its em loyees aze inv ved and/or res nsible for our damages. �'Yi 4 � 1 O 1.�" ' � t' � c �U r � C A3 S t dlv � 2,r1 '' S .D 1 fl i 're , ( - � r Cc�M-�LA��i � l�I�� w t�t.r � z't� �lr 1 DRYC �r C�2 .�, Please check the box(es)that most closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident I ❑ 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 spec,�if}' �Other type of injury—please specify S i C �Q �'•l�: R�i' � � t`�' In order to process your claim vou need to include couies of all aanlicable documents. For the claims types listed 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: legible copies of any ticket.issued and a copy of the impound lot receipt O Other propeRy damage claims:two repair e�stimates if the damage exceeds$500.00;or the actual bills an�i/or receipts for the repairs;detailed list of damaged items �Injury claims: medical bills,receipts O Photographs are always welcome to docurnent and support your claim but will not be returned. Page 1 of 2—Please complet 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—please complete this section Were there witnesses ro the incident? Yes�, No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes�� No Unknown (circle) If yes, �vhat department or agency? '�`��`�-+� Case#or report# Where did the accident 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. Please indicate the amount you are seeking in compens�tion or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims—nlease complete this seetion � � ,,�check box if this section does not applv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner I � Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims— lease com lete this seetion ❑ check box if this section does not a 1 How were you injured? S'�►'��j'� C.� C S� 1�� #- j i7 ��'1�4i What part(s)of your body were injured? N `� `� s �: ( +� "�+C' Have you soubht medical treatment? e�.- No Planning to Seek Treatment(circle) When did you receive tre�tment? � � �" �1 (provide date(s)) Name of Medical Provider(s): E trl iZ/,.:Z'�� C�?, ��'1 �`�)j L�� C i��.� i t/Z Address Telephone 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 pagcs to this claim form. Number of additional pages By sigrting tltis fonn,you are stating that all irtformatio�t yoi� have provided is true and correct to the best of your k�towledge. ZI►isigned forfns will not be�broeessed. Submitting a false claitn can result itt prosecution. Date form was completed "� "" `Z "" � _.� �- f , Print the Name of the Person who Completed t F ? � � Signature of Person Making the Claim: � '' Revised February 2011 ' 06-04-2013 On 03-16-2013 while arriving at the St. Patric's Day Parade, my son Harrison was in a large crowd of people. The police were coming through the crowd and passed by my son with no incident. These police were followed by police on horses. When a horse stepped on my son's foot, he reacted as anyone would by screaming and pushing the horse. At this time he was attacked by police officers & held by 2 officers while the officer on horse back continually kicked him in the groin. He tried to protect himself from further injury, but not resisting, & was thrown to the ground, has a taser held to his head, & h�ndcuffed. He was then hauled off to detox. His foot was injured & bleeding through his shoe. He continually ask for the Fire Department Medics to be called but was denied medical attention. I am a retired Firefighter & former Dakota County Special Deputy, so I know the actions of these police officers was not warranted & should never have been allowed to happen under any circumstance. The police officers had absolutely no intarest in my son until he reacted to being stepped on by the horse. 1 immediately notified the SPPD Chief. I was later contacted by Sgt. Gora SPPD IA. Today I received the claim form. I totally hold the City of Saint Paul responsible for the injury, mistreatment, & expenses incurred by this inexcusable incident. Harry F. Rund IF PAYfNG BY CREDIT CARD.PLEASE SELECT CORRECT CARD AND FILL OUT BELOW � � — .�__i (� ❑ ISGBVER ❑ .,.,_ I ❑ j/� 257 West St. George '�_�J � Grantsburg,WI 54840 CARONUtdBER EXP.DAlE MAOUNT .�,�>i„ohr_,rt��t%=^��'��.�:�-��:`«<<+:�� `71`��YV3-53J� SIGNATURE MUSTINCLUDE3DIGIT SECt1RRY CODE FqOM BACK UF CARD STATEMENT DATE PAY THtSAMOUNT ACCOUNT NUMBER �Please checA bos ff below address is incortcct and ind�catz c6aneels)on recerse sfJt. O�/I�/�" 606.37 109107 ADM te 956657 SHOWAMOUNT Q PAID HERE `� RUND, HARRISON W BURNETf MEDICAL CENTER = Y` 358 6TH AVE N =� SOUTH ST PAUL, MN 55075-2044 257 W SAINT GEORGE AVE GRANTSBURG, WI 54840-7827 I��11�11��1��'�I'llll��l�ll��l�l'I��'�I"��I�I�I��'�I'i'i� PLEASE DETATCN AND RETURN TOP PORTiON WITH YOUR PAYMENT I�age: 1 ofi 1 DATE DESCRIPTION CHARGES PAYMENTS �SURANCE PATIENT PAY PENDING (YOU OWE) ' 109107/ 956657* RUND, HARRISON W 03/17/13 HSP:0001 EMERGENCY 647.00 ACCUM. PAYMENTS -64.70 BALANCE DUE 582.30 Q3/17/13 PR0:0001 EMERGENCY 146.00 04/19/13 INSURANCE PAYMENT .00 04/19/13 CONTRACTUAL ADJUST -121.93 BALANCE DUE 24.07 � I� � ' MESSAGES TOTA� �Np�DiNG E A NOW u PAYMENT IN FUIL 6�6.37 0.�� 6a6.37 is expected.if you are ' unable to pay in full, I ACCOUNT NO. STATEMENT DATE' RETAiN THIS you must call our coav FoR Financial Counselor at 109107 05/15/13 VOUR RECORDS 715-463-7247.Thank you! Burnett Medical Center•25�West St.George•Grantsburg,WI 54840•Phone:(715)463-5353 Ramsey County Detoxification Center 160 E. Kellogg Boulevard, Room 9200 St. Paul, MN 55101 Office Telephone: 651.266.3529 Statement Date: 04/25/2013 Page 1 of 1 Client Name: HARRISON RUND Account Number: 106698 RUND,HARRISON WILLIAM 358-6th Avenue, N. � AMOUNT ENCLOSED: South Saint Paul, MN 55075-2044 I VISA/MASTERCARD PAYMENTS: To pay by Visa or Mastercard, please call our business office at 651.266.4032 ta provide your creuii card inior�r�atio�i. Tnank you. -- — — -- -- -- — Make Checks Payable to: RAMSEY COUNTY HUMAN SERVICES — -- -- — Please Detach and Return Upper Portion of Statement with Payment -- - - - — - �.�.� . 1�� Ramsey County Detoxification Center---Charge and Payment Detail for the Period Ending 03/31/2013 �_._._�. Questions about these charges? Please call 6511.266.3529. Unpaid services through 03/31/2013: Service Date Tvpe of Service Amount Owed Runninq Total 03/16/2013 DETOX DAILY RATE $235.00 $235.00 Payments posted to your account within the past 90 days: Date of Service Pavment Date Tvpe of Pavment Pavment Amount Pavment Applied To Total Amaunt Now Due: $235.00 I I Messages: i � -�i^� a a..:�i?3 � - �. : � ��, -u,.; � DIAGNOSTIC RADIOLOGY ASSN. -0F WI , ,, ��d , : �. #3 } # � y;,,,_ 1024 N0 MAIN STREET �,�*;,..�� ,� ��`��„ r.�: ., s�. .< RICE LAKE, WI 54868 180226 44.66 ! 5/Ol/13 . . : IPPAYINGBYCREDRCARD P FI T K . . � . . . � . � . . .. . wu•.c..� ,� yUA` . . .. � ' MASTERCARD VISA ADDRESS SERVICE REQUESTED - __ _- _ � � - __— � -_ - i PHONE: 1-800-428-7226 _ -_ _�=_ HARRISON W RUND DIAGNOSTIC RADIOLOGY ASSN. OF WI 358 6TH AVE N 1024 NO MAIN STREET SOUTH ST PAUL, MN 55075-2044 RICE LAKE, WI 54868 i��il�li�Il�iilllili,.il�i�liiN��iiiiii�n�ll��ll�iiil�llu�ill 0286o nllli�l�nlllli�i�ii,i��„�,y,�,i��i��ii�i�iil�ini�,i�,i�,iil � -. . tr� .,��, . , � � � � � • �� _,. � .. .,.- _ . , . ��,�'�" DIAGNOSTIC RADIOLOGY ASSN. OF WI - 3/17/13 HARRISON FOOT COMPLETE MIN 3 VIEWS 50.75 � , ' 1119890 MEDICA (SALT LAKE CITY PO filed Paperless ' 4/26/13 HARRISON MEDICA APPLIED $44.66 TO DEDUCT � 4/26/13 HARRISON Allowance for MEDICA (SALT LAKE CITY PO 3 6.09 I j __ _ _.._..__ _ , �_.._,� _ ._ . _ __ � f � I _ ... _. _ I _ _ _. . _ _ _,_ _ __ __ . _ _ ____ _ _ _ _ _ _ _ _ _ i ., _. __ _ _ __ . . _ . _ ,. �� _..� - <' , ' 180226 ; 5/O1/13 44.66 , ; 44.66 ' , , , , _ ___ . .__ _ __ . .. __ _ _ _'_ __ _ _ _ __ � _ �„P:�, �.�..,.. ..:...„,�.� For questions regarding your statement call (800)-428-7226. We now accept Care Credit Please-.call for more information! " ,-#"�"'-'•.. _ _�,