Adams �I�g�� L�� �°ir� RECEIVE� .
2915 Wayzata Boulevard AUG 14 2013
Minneapolis, Minnesota 55405
Phone: (612) 767-1871 CITY CLERK
Fax: (612) 767-1872
www.magnalaw.net
August 9, 2013
City Clerk
15 West Kellogg Blvd.
310 City Hall
St. Paul, MN 55102
RE: Our Client: Ms. Janesha Adams
Date of Injury: 07/OS/2013
Dear Sir/Madam:
Please be advised that we represent Janesha Adams for the injuries sustained in an incident
occurring on 07/OS/2013. Upon information and belief, Ms. Adams was viciously attacked by a
St. Paul Police Department canine while she was in her apartment building located at 1749 E.
Montana, St. Paul, MN 55109. As such, because of police negligence and recklessness in this
matter, our client sustained serious injuries.
Enclosed for your review is the Notice of Claim Form to the City of Saint Paul, Minnesota,
putting this municipality on notice of our client's injury. We would appreciate if you would
provide us with copies of any reports, notes, photographs, statements, video and/ar surveillance
tapes of the incident, witnesses and our client.
If there is other preliminary information we may provide you with, please contact our office.
Please do not contact our client directly.
Very truly yours,
�
Oliver E.Nelson, III
OEN/mf
Enc.
RECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesql� 14 2013
Minnesota State Statute 466.05 states[hat "...every person...who claims damages from any municipaliry...shall cause to b� e E R K
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the tim , a e, n
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 CLER�
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 ,� c m
First Name �1�v�Vr Middle Ini[ial � Last Name Ne I s o�, �-' � ��,,, n
Company or Business Name � V� vJ t"��N�1 t-�-e- _� N �
° m
Are You an Insurance Company? Yes,� If Yes, Claim Number? � `.,
Street Address q I S W�'t 0. C�. v
�z �Z � (�Ivd .
City �in►�cc��p01�S State M� Zip Code �Sy� S
Daytime Phone (6�Z.) `76��]L Cell Phone�2�) 3$- 3032,Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 7�8�I 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.
e. e r c � c � --' s . G i¢ � �a l.«
a G� g'�. o �L e r�i
i � s � �
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 bf the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was iniured on City pronerty
❑��ther type of property damage-please specify
IId Other type of injury-please specify �������in S�-o w�.cc c
In order to process your claim vou need to include copies of all auplicable 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-nlease comnlete this section
Were there witnesses to the incident? � No Unknown (ci le)
Provide their names, addresses and telephone numbers: To (o� �1e{'crw�t�e.�
Were the police or law enforcement called? � 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 park or facility,
closest landmark,etc. Please be as detailed as ossible. If necessary, attach a diagram.
t 7 4 9 � I(Y\o n�a.�.. .�k � �Q.u\ ,b tJ ,�S 10 9
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.
u.� I\ow� a i s
Vehicle Claims-nlease comnlete this section t'J check box if this section does not avplv
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 � check box if this section does not a 1
How were vou iniured� a��c.c_ �n�i
. .. .-�_ --
What part(s)of your body were injured? o w�u-C,
Have you sought medical treatment? �es No Planning to Seek Treatment circ
When did you receive[reatment? -7-5-13 � (provide date(s))
Name of Medical Provider(s): Q,ew i o n S �o S p� a.�
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of yoar Employer:
Address Telephone
C9'Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this forni,you are stating that all infotmation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be p�ocessed.
Submitting a false claim can result in prosecution. Date form was completed��� � � � ! 3
Print the Name of the Person who Completed this Form: � ��`'�� � � �`� x �"'`�" �`/��''` �`�
r1a.1�cr,
Signature of Person Making the Claim:
Revised February 2011
�
How do I file a claim against the Cit�
Fill out a claim form and return it to the City Clerk's Office. The matter will be examined
by the City's claims manager, who will contact you. This process can take up to ten
weeks.
Claim forms are located online at http://www.stpaul.gov/index.aspx?nid=186 or by caliing
(651) 266-8688. Claim Form
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