Smith, Whitney NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statzete 466.05 states that "...every person...w/to claims damages from any municipality...shall cause to be presented to the
governing body of t/ie municipality within 180 days after tlie 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 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 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
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 : �`������ Middle Initial�Last Name J�h,� R —�^.��CD
: Company or Business Name
- ., --- --- , �` � 13
Are You an Insurance Company? Yes/` o If Yes, Claim Number?
Street Address t � U�V�� CITY CLERK
City ��. �d�d/� State �N Zip Code� u�Z
Daytime Phone(��-�QZ Cell Phone�) 373-��°�$ Evening Telephone ro�l ,3�- 1 b9 B
Date of Accident/Injury or Date Discovered � �Z� � � 3 Time �� ,3� /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 employees are involved and/or responsible for your damages. C1�� '�'fuCk Wt�S
r . n2e.�- a� ���$ �.ir�� �for� .2 13�` - -ec�
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C W e✓ (ti S �I' GV W V� • �G ol,
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io�e Co rt - �'Y1 U�� is h �,n��i' "� ho� 1 � ' wQ�
s �h� � � � ��� � y�
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
l7 M�vehi�le was�,ror�gfizLly tflwed and/or ticketed n I�xas injured on Cit3�property
❑ Other type of property damage—please specify 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
O 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
/
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section l(o S��35�3'lo ���
Were there witnesses to the incident: Ye No Unlrnown (circle)
Provide their names, addresses and telepho e numbers: ��iu� ��0 2i�e r 2b 1ti (,0�S�. ��-P'�, M�1 SS�a2
s 13 f�n e S�; s � -�o
�-- � �o�c� I 3S� '�.r ri +�n -e . p�w (oSl ioO -(�l�
Weri he police or law enforcement calle ? Yes No nlrnown (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 park ar facility,
closest landmark, et . Ple se be as detailed as possible. If necessary attach a diagram.
�35�3 �arrina►�vn �� s�.p�wi rn� �� is c.. dea..e� � ��e�- _
Please indicate the am unt ou are_seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicie Ciaims Ulease complete this section ❑ check box it this section does not applv
Your Vehicle: Year 2pE0 MakeTd �l. Model ra��� ^��
'`� � State i'�1N Color S i lUQ r
License Plate Number ����-{
Registered Owner 1(�1�� S'
Driver of Vehicle � Y+l�
Area Damaged �1.` '11� � A�v�� V �" � i n� D v✓
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In�urv Claims please complete 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 o 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 inj ? Yes No
��Vhen did y�u r_miss vv9rk? _ __ (provide date(s))
- —----- ---
Name of your Employer: �
Address Telephone
�heck here if you are attaching more pages to this claim form. Number of additional pages 1 ( .
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 processed.
Submitting a false claim can result in prosecution. Date form was completed �I���
Print the Name of the Person who Completed this Form: �'�
Signature of Person Making the Claim:
Revised February 2011
Cost of items destroyed:
Parts to get the truck started again with towing: $490.89 (my dad did all the work)
School text books: $ 250.00
Tennis Shoes:40.00
IPod: 150.00
Truck interior: Unknown$
The Cloth interior�the smell has not gone a way as of today I have tried to dry it, cleaned it and now
trying to air it out..
I am very afraid know that my truck that has been submersed in water that it will have many problems
in the future. It is finally running after buying all the parts that needed to be replaced in order to get it
started I really feel the$2000.00 dollars I am asking for is a far amount for the damages to the car, my
personal belongings and as of today it is NOT worth the blue book value at all due to the water damage.
Thank you for your time in looking into this claim which is truly an unfortunate incident.
Whitney Smith
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Cost of items destroyed:
Parts to get the truck started again with towing: $490.89 (my dad did all the work)
School text books: $ 250.00
Tennis Shoes: 40.00
IPod: 150.00
Truck interior: Unknown$
The Cloth interior^'the smell has not gone a way as of today I have tried to dry it, cleaned it and now
trying to air it out..
I am very afraid know that my truck that has been submersed in vvater that it will have many problems
in the future. It is finally running after buying all the parts that needed to be replaced in order to get it
started I really feel the$2000.00 dollars I am asking for is a far amount for the damages to the car, my
personal belongings and as of today it is NOT worth the blue book value at all due to the water damage.
Thank you for your time in looking into this claim which is truly an unfortunate incident.
Whitney Smith
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BUDGET TOWING INC. �F ST. PAUL
�` -''� t� 560 RANDOLPH AVENUE•ST. PAUL, MN 551.02
24 HOUR SERVtCE-RADIO DISPATCHED
MODEL COLOR CARS+TRUGKS ��O�F O�
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`' .' t� PHONE 651-771-8817
tiCENSE NUMBER R.O.NO.
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�� � VEHICLE DESCRIBED ASOVE AND ALL PERSONAL PROPE�TY THEREIN IN iTS PRESENT CONDtTION AND A EE NO FURTHER
CLAIMS WILL BE MADE AGAINST BUDGET TOWING INC.C�ST.PAUI. i
NOT RESPONSIBLE FOR DAMAGE TO VEHICLE �
FET � BEYOND OURSCONT OR IOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE.THEFT OR ANY pTHEH CAUSE
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