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Thomas r�����l �!�LJ � . � � / � �p�� JUL 02 2013 �' 'Y`�� NOTICE OF CLAIM FORM to the City of Sain��l�r�sota Minnesota State Statute 466.05 states that "...every person...who claims damages from arry municipality...shall cause to be presented to the governing 6ody of the municipaliry within 180 days a/ter the all�ed[oss 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 ty ing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you '1 not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,an the amount of compensation being requested. You will receive a written acknowledgement once your form is received. he 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 J��"�u' Middle Initial J Last Name ��o���' Company or Business Name J J T�4 c. f� � �0�Lt� �E�Cv sc.�r ��u�. � Are You an Insurance Company? Yes/� If Yes,Claim Number? �'' Street Address 2 �� � • $ T� sT City �'T �A'v L State �N Zip Code '������ Daytime Phone(��) �ZY- a24� Cell Phone(6�!��ZZ- 3moi Evening Telephone ?� �� gs'�� Date of Accident/Injury or Date Discovered /—/O - Z O�2 Time pm Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you �I feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ' FAiLV�.[ �F ST P�fvL QC6/a►.v i1-L L.��Tt�G S'E�Evt P/� /¢'T Z�t! ��T T 8' 'r.[� T rt¢t r- /�filt.�b T B�.t��c r���✓ 7'0 8'' G'N-r r >t�rv �it�N l�s.I-�-ct L �kt. /�w d T��c.Ep /•v / � 9'7. jT�.�-.s F'.a.�.vct E.�-astp s✓.�t-rc.�c r-- J�.d�r�e�rt- �Q,tl�esr /w� �C3 r!-s c rrt�r- a�� pi�e:a�.�t�'�Y �N-ur rYo �� 2?o � 8'� p T� s v e s �cQ��.�r �'f e��r3 5'rt�E�.w �•�o ,D•�r.fs t �.vc v.[..tE o. AN� StpE�v!fL� Please check the box(es)that most closely represent the reason for completmg this form: ❑ My vehicle was damaged in an accident . ❑My vehicle was damaged during a tow ❑My vehicle was damaged by a pothole or condition o�f the street �My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed I, ❑ I was injured on City property s^��rtc.� 1ZI Other type of property damage—please specify OM-�tA-e'E ��•�r�r �� /��«a0 w�`�� ❑ Other type of injury—please specify In order to process your claim vou need to include couies of all auplicable documents. For the clairns 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 andlor receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt � Other property damage claims:two repair estimates if the damage exceeds$500.00; or the actual bills andlor 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 - � e�ti �.'W�! CG �Z-�1� �• d32y \ . Failure to complete and return both pages will result in delay in the handling of your claim. k. All Claims—nlease comulete this section Were there witnesses to 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,what department or agency? Case#ar 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 compensation or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Clairns—olease complete this section ❑check box if this section does not applv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged i City Vehicle: Year Make Model License Plate Number State Colar � Driver of Vehicle(City Employee's Name) ' Area Damaged In'u Claims— lease com lete this section ❑ check box if this section does not a 1 How were you injured? What part(s)of your body were injured? � Have you sought medical treatrnent? Yes No Planning to Seek Treatrnent(circle) I 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 yoa 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 . I 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 processea� Submitting a fulse claim can result in prosecution. Date form was completed Print the Name of the Person who Completed this Form: � �4�c.[S J �N,oNt�. Signature of Person Making the Claim: Revised February 2011 � . ,� .. . � Date 3/21/13 Holes and Depressions & Property Information Reported �� R Address# '70 ighth Street ast I E Sidewalk Damaged Yes Depress/Hole Location riv.Prop. N P Street Damaged Yes How discovered? roperty Owner I O Curb Damaged Yes ' ,I, Reported By: roperty Owner , R Rat Hole No ,I, Reported To: Jennifer Ziemer Time Eztension: Status Inspector's Feilds � Inspector sent? eS Insp Date 2/$/13 � ,I, -7-13: Property owner called with complaint of water and sand in basement. Searched ecords and found that water main work was done on 1-11-13 and 1-18-13,wo.# � 1300313 & 1300291. Sent service request to sewer mtc.to TV main for sand.2-8-2013: Entry Format: insp. showed main to be clean and service is open at main,po.may want to tv � Date-Comments - ervice to determine cause of sand in basement. Init. /22/2013 Jim has been in contact/discussion with Kevin Nelson about vacating 8th St � -- -- --- d turning it into a green space. JZ � /27/2013 Sewer service was televised. PO came in with DVD. DVD was reviewed ' I d determined that sewer service is OK. LL � ' .O.Jim Thomas ' 1140 Riverside Drive North Hudson,WI 54016(USA) jjt1140@comcast.net j im@l ancerservice.com www.lancerservice.com 715.386.8831 home 612.723.3001 cell P OC :PIN#�' �i �� � 312922440354 R Permits Violation Date M. Letters sent. 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