Rappley REC�ivEo
� JUL �s 20i3
NOTICE OF CLAIM F�t�t�l��;�;ty of Saint Paul, 11►�Iinnesota
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Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...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 l�is 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 acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
natare of your ciaim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND O�HER DOCUMENTS TO: CIT'Y CLERK,
15 WEST KELLOGG BLVD, 310 ITY HALL, SAINT PAUL, MN 55102
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First Name �-���%I Middle Initial � Last Name ��'��1���-1
—��
Company or Business Name
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Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address ���- ��-�.�,� �N�"Piv� ��U E ��,
City�� �G�i,�- State �� Zip Code �4�
Daytime Phone(�I)�- �1�-1� Cell Phone(�)�- 11(>�j Evening Telephone( ) -
Date of Accidend Injury or Date Discovered I�JJ�f}I�I�1� Time ���� �pm
Please state,in detail, what occurred(happened), and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its emplo ees are involved and/or responsible for your 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
❑ 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 prope ^��
�Other type of property damage-please specify?�h(Y�reL �IM-��(.t.�t`� 1�L�'1��p I (�� �'
Other type of injury-please specify
In order to process your claim vou need to include copies of all applicable 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
�! 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
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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 to the incident? Yes No Unknown (circle)
Pr�1 e their names, addresses and telephone numbers: � �
1��V'A/1�1 �;'�i"C�f�( ^ � , � � y'�(�— � ��' ��L('� a.�.�_. ► � � �
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Were the police or law enforcement c led? ��' No Unknown (circle)
If yes, what department or agency? f Case#or report# �,/�Vw�
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 necess , attac�a diagram.
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Please indicate the amount you are seeking compensa ion or wha you would like the City to o to resolve this claim
to your satisfaction.
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Vehicle Claims— lease com lete this section eck box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
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 section eck box if this section does not a 1
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
Check here if you are attaching more page to this claim form. Number of additional pages�.
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By signing this form,you are stating that all inf ation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be�rocessed.
Submitting a false claim can result in prosecution. Date form was completed �7 �. >
Print the Name of the Person who Completed this Form• ��-c�� �J• ���
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Signature of Person Making the Claim:
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Revised February 201 I
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I have called and complained about the city—owned tree on the boulevard adjacent to my property at
2054 Stillwater Ave East in St. Paul at least four times. The tree is located on the Manitou Ave side.
Its branches are over the xcel power lines and have caused damage to my house by pulling off the power
mast twice! The last time was in November 2011, when we had a snowstorm that broke a branch off
and it pulled the whole thing down. I had to pay over$500.00 for that repair. It happened again last
Friday (June 21Si, 2013), again causing damage to my home and pulling off the power mast. I again had
to have the power mast replaced, again at a cost of$457.00 (a copy of that invoice is attached); as well
as due to losing power I lost over$100.00 in groc ries. I have called at least twice in the past two years
to have the branches trimmed, because they wer�TOUCHING the power lines! I am requesting to be
reimbursed for the replacement of the power mast and for the groceries. I am a single person who lives
paycheck to paycheck and I cannot afford to keep repairing things due to a tree that is obviously not
healthy or was not planted in a good location. � ��(1���,�� �l� G'� � � �JOV•Uv������
The tree has been marked to be taken down, so I know that it is not healthy. It has the number"20" on
it with a large red circle.
I am requesting to be reimbursed for the$457.00, plus $100.00 in groceries lost due to losing power
ONLY because of the city's tree damaging my home.
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� :�f�YARD ELECTRIC COMPANY INC.
�� 7087 PROGRESS ROAD
fj CENTERVII.LE MN 55038
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//" Phone 651-426-2444
� Fax 651�26-6153
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KELLY JO RAPPLEY
2054 S'TII.,LWATER AVE
ST.PAUL MN 55119
SERVICE RISER, STOR�VI DAMAG�
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2 1" MIlVERAL-LAC & BOLTS
10 FT SCH. #80 PVC PIPE
3-FT SCH. #40 PVC PIPE
1 1" PVC FITTING '
1 WIRE HANGER Ki�OB
NIISC. MATERIALS
5 HOURS LABOR SUB-TOTAL $ 404.00
INSPECTION FEE $ 53.00
TOTAL $ 457.00
THAI�II�YOU
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