Pawlitschek NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Stnn�te 466.05 states thnt "...every person...who clnims dumages from anv municipulity...shall cae�se to be presented to the
governing bodV of the municipnliry within 180 dnys nfter the nlleged loss or injurv is discovered a notice stating the time,pince,nnd
circumstnnces thereof,and the amount of conrpensation or other relieFdemnncled."
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 �CA�„� � � �s c����
Company or Business Name
�� RECEIVED
Are You an Insurance Company? Yes No If Yes, Claim Number? SEP 0 4 2013
Street Address �'�7 � S���.��n � ClTY CLERK
City S�, �_ / State /f/1 ..t/ Zip Code .S~S�'/ U 3
Daytime Phone (6.S'! )�j S�- 1 6 / Cell Phone ( ) - Evening Telephone ( ) -
Date of Accident/Injury or Date Discovered r�;�� � �S' Time .`�O am/�
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.
,� Y� l.!... � ✓� /�6, r/� ���� /4 rl O I�O L�� �I �L_ J�i P '�,�./'�rt�f
/' +�t-c,�=
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-ulease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone mbers: .��o�I Lf 7�! ���Y��� ,-N..
Were the police or law enforcement called? Yes � 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 ark or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. _�/�Z:Z S'�,�/��.,�,,,,� .� „�
f'f. /a��_ I ,� .,�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfactiory��CY�; o��
Vehicle Claims- lease com lete this sec 'on ❑ check box if this section does not a 1
Your Vehicle: Year�_Make c Model �
� License Plate Number State .t,' Color _ G ���,
Registered Owner ��,� «�,� ��� ��T�-,6�.P�
Driver of Vehicle .���I ��r �
Area Damaged �=���- -e;��f
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-nlease complete this section ❑ check box if this section does not ap�lv
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 this claim form. Number of additional pages
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.
Subrraitting a false claim can result in prosecution. Date form was completed � ' 1`� - �-�
Print the Name of the Person who Completed this Form: �✓ �' �=N� �;, ;.,1�, ���� aC
Signature of Person Making the Claim: ���,n_` - �%,,r�<�f���
Revised February 201 1