Chapman � �r�s���.�c�€�p�� -�or ��[��� l�a��c� a�� �I������ �a �E�y o�� ��E�t ���€� " ,
ll4rnnesota State Statute �66.05 NOT/CE OF CLAIM.,.(E)very person...who claims damages f�om any
municipality...shal/cause to be presenred to the gove�rning body of the municipality within 180 days afte� rhe
alleged loss or rniury is discovered a nntice stati;�g the time, place, and ciicumsrances the�eof, and the amount or
compensation or other �elief demanded.
Fizase complete this fori�� in ifs entirety by typing or printing your answer to each questibn in
tl�e space provided. If additional space is needed, please attach additional sheets.
-�-� r' PLEASE RETURN THIS Uffice of City Clerlc RE�r�����
COMPLETED FORM T0: 170 City Hall SEP `�t� ���
15 W 1<ellogg Blvd
St Paul MN 55102 (���( (�����
Your Name: �(�n �`lp� (�,�.��r� y�
/ - ---- —___--- ----- ..__... _ _ _-- -- __ ,___---___
- Street Adcliess; .._T �-�� -��� �G1'1nV�-�1'3C_.�-.�- �
City: State: �� Zip Code: ��
Daytime Telephone: /��� � ('��'2� �� Evening Telephone: _ ( )
Date of Accident or Incident: ��Day of U✓eel<: Time:g�_ rr or pm (circle one) ,
v
Please state, in detail, what occurred and the circumstances surrcunding the event. Indicate how the
City of Saint Pa�f is involvecl; �nd why you feel the City is responsible.
, �
O�r - u '�t�i IN�F N
O� � a ..� '�.
a -. �c
Please indicate your reason for completing this form;
,;
(..1 Vefiicle accident -�1 Other property damage (please provide specifics below) ;;;�.j;
; �„
`��f ��c1.G 2� C�'� Y1^ / Q�01 / ln "l O�C „�['a, i;;
'� Vehicle was towed _�� �
�J �j�;
❑ Vef�icle damaged ❑ Otl�er in jur y to person (please provide s pecifics below) ,�i��
❑ Slipped and fell. on City property � �� �
,
��
;;:1
Please provide tl�e names and telephone numbers of any City employeas involved in this i ::
incident/accident and I�ow tt�ey were involved: �
� ,I.
E„r[..o e.v� �r �-o�-e� w,� �o�r �.s��e►� � w �`� � o ��� � � , ;
.�1 p��i � r a s �, c��,r.-e c�.���� r'` �
'L� o�r..
(over)
��
� �,
If your vehicle �n�as involved, please complete ihe follo�n�ing:
1'ear, mal:e, and m�oael: License Plate (Vumber: �
Exteni and area damaged:
Was a City vehicle involved in tf�is acc�dent/incident? 1'es No (circle one)
If yes, piease complete the following: Type of vehicle
Year, mal<e, and model
Color of vehicle License Plate Number: -
Description of vei�icle
Location of accident/incident (please provide specifics suci,� as street address, intersection, cross streets,
park name, facility name; etc.�:
_ _Please_draw or.attach a diagram_i_f_a�plicaf�le:
Please specify the nature and extent of the comrensation or other relief yeu are reques;ing. Please
attach copies of any bills, receipts, ticicets, or other docum�nts to support your claim. If you are
claiming damage to a vel�icle, please sub���it two estimates.
Were there witnesses to this accident/incident? Yes No (circle one;
If yes, please �ive the names, addresses, and telephone numbers of the witnesses;
\Nere the police called? Yes No (circle one) If yes, what department or agency? �
Police report number
Please print the name of the
person completing this form: ' (1 (�, :
Please sign ;�our nome:
V � �
f
Daie form signed:
�?��-2 � f� �
i.
Fiisl< Mgmt Division - Aevised 1-30-01 '�'?�ii:�
;;_a;�i!'!:��'� '
,,,,;�,,;.�.
t. ��: