Fisher , RECEIVED
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NOTICE OF CLAIM FORM to the City o�l�'t����tnnesota
Minnesota State Statute 466.05 states that"...every person...who c[aims damages from any municipality...shaU cause to be presented to the
governing body of the municipaliry within I80 days after the alleged loss or injury is discovered a notice stating the ame,pktce,and
circumstances 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 ques�on. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarlfy answers,so provide as
much information as necessary to explain your daim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. T6e 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 ST KELLOGG BLVD,310 CITY HALL, SAI T PAUL,MN 55102
First Name 6 U Middle Initial / Last Name � �-.�L cP �'
Company or Business Name
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address ���� � ,� �
City ��• Q,�� l State �"t Zip Code �Y�� /
Daytime Phone(��`')���i���ell Phone( )� - Evening Telephone( ) -
Date of AccidenV Inj ury or Date Discovered�,��y '�� "�/�Time,�.(,�.` / m
Piease state,in detail,what occurred(happened),and why you are submitting a claim.Please indi te why r h you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. � ' ���
— i i
Please check the box(es)that most closely represent th�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 �
J�'l�iy vehicle was wrongfully towed and/or ticketed ❑I was injured on City property ;
Cj Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claim you need to include conies of all au�lfcable 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 WII�L 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 property damage claims:two repair estimates if the damage exceeds$500.00;or the actuai 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 retumed.
Page 1 of 2—Please complete and return both pages of Claim Form
On June 26, 2013 at around 10:00 am my car was
tow from the driveway of 1175 cook ave e. When asked
the police that was there said that a letter was sent to the
landlord stating that the car was to be towed because it
was in violation. None of this made since because by law
if a car is sitting on the street and looks disabled for more
than 48 hours it can be towed. Yes my looked disabled
because I was working on it and had parts off of it
including the bumper. But my car was not on the streets it
was in the driveway of my mother home and it was not
sitting longer than 48 hours. I park the car at 1175 cook
on June 24, 2013 at 6:00 pm to do some need work on it
and left it in the driveway at around 9:00 pm because of
the lack of light and parts needed. I was unable to return
due to work and again lack of parts but was going to
return when I got the much needed parts. I feel that it was
wrong that the city can just come on to someone property �
and take whatever they want. I feel that the police officer !�
on due should have read the notice better because there �!
was no way a letter was sent out about my car.
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—olease comulete this section
Were there witnesses to the incident? es o Unkno (circle)
vide their names,addresses d te ephone numb rs: � f0�2 '�
� 26 /% .�
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of pazk or facility,
clo t landmark,etc. Pleas be as detailed as�o sible. ff necess ,attac a dia am.
il��' �',�,�� ��� f �—� � A�/ ���' ��d .,
Please indicate the a nt you are seeking' co pe atio or what you w uld like the City to do to reso ve this m
to your satisfaction. " � 'I �1� U �
� �- r
Vehicle Claims— lease com lete this secfion ❑check box if this section does not a 1
Your Vehicle: Yeaz�?!`�G I Make (/Lc7 Model
License Plate Numb '� Stat -JI ol �
Registered Owner � � ��
Driver of Vehicle��-+-��j�.��� �--i S l�.D r�'
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please comnlete this section �check box if this section does not applv
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 pages to tl�is claim form. Number of addifional pages
By signing this form,you are stating that all in,formation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed s �
_.�
Signature o#Person Making the Gaim•, � � '
Revised February 2011 �
7/16/13 1175 E�t CodcA�enue,Saint Paul,MN-Google Maps
To see all the details that are Hsible on the
screen, use the"Print" link next to the map.
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Name �
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DOB(mmidd/yyyy) Eyes Height Weigh# Sex Race Ethnicity ;
Vehicle License No. Plate Year State Make Type Model Color E
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❑Speed 169.14(subd ): mph zone ;
❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) �
AC Taken—AC: Test type: ❑ Refused ❑ Breath � Blood O Urine ;
❑Hazardous Material (DOT) ❑Unsate Conditions ❑School Zone �
❑Endangering Life & Property ❑Work Zone ❑Commercial Veh. DOT#
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Ll No Seat Belt Use 169.686.1(a) ___._.___--
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