Schultz ' � NOTICE OF CLAIM FORM to the City of Saint Paul, Mqinnesota
Minnesota State Statute 466.05 states that"...everyperson...who claims damages from any municipality...shall cazl�,46 b�pi'�s�hZe�to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice statin the time la
circumstances thereof and the amount of compensation or other relief demanded."C�TY �'L��
Please complete this form in its entirety by clearly typ�g or printing your answer to each question.If more space is
needed,attach additional sheets.Please note that you will ot be contacted by telephone to clarify answers, so provide as
much informarion as necessary to explain your claim,and the amount of compensarion 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 O'�'HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
Fizst Name Diane Middle Initial� Last Name Schultz
Company or Business Name
Are You an Insurance Company?Yes /��If Yes,Claim Number?No
Street Address 163 Front Avenue
City St Paul State NIN Zip Code 55117
Dayrime Phone (612, 33L 5-1831 �Cell Phone�_) Evening Telephone(�6511487-331 G(Hl
June 21,2013
Date of Accident/Injury or Date Discovered Tune 2:00 a.m. /pm
Please state,in detail,what occurted(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. During the severe storm,one
of the large boulevard trees was knocked over and fell into m�yard I re�orted that to the Fores�Deuartment and thev will
take care of cuttin�down the tree,but mv fence was broken b�the tree falling into m��ard. That�ortion of the fence will
need to be fixed.
Please check the box(es)that most closely represent the reasbn 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 condirion of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wroi�fully towed and/or ricketed ❑ I was injured on City property
�Other type of property damage—please specify Boulevard tree fell and broke m�fence
❑ Other type of injury—please specify
In order to process your claun��9u 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.Documen�WILL NOT be retumed and become the property of the Cit�.You are encouraged to keep a copy for
yourself before submitting your claim foYtn.
O Property dau�age 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 tlze repairs
O Towing claims:legible copies of any ticket issued and a copy of the impound lot receipt
� Other property darnage clauns:two repair estima.tes if the datnage exceeds$500.00;or the
actual bills and/or receipts for the repairs;detailed list of damaged items
O Injuty 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—alease complete this section
Were there witnesses to the incident? Yes �� Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes o 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 possible. If necessary, attach a diagram.
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.
Vehicle Claims—please comelete this secfion �check box if this secrion does not a��ly
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
Iniury Claims—�lease complete this section �check box if this section does not annlv
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--� �Q'� �
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.
Sub»titting a false claim can result in prosecution.Date form was completed �—'26 j 3
Print the Name of the Person who Completed t ' Form: P c�. � Z
^� .
Signature of Person Making the Claim:
Revised February 2011
, � JAN 08 '96 22�02 FR TO 96123351657 P.02i02
MI�WEST F�ME A �N��' Ca. INVOICE
5zS EAST VILLAU
gqLITH ST. PAUL, MN 55�75
iNV010ENUMBEFi�SOO21 SOUrCe:
PHONE (6S1) 451-2221
FAX (651} �51-693� INVOICEDATEO�I2���3 Ozder Q57158
PAG6: 1
�CHULTZ�, DIAI�E
SCHULTZ, nI�E SH�P: 163 FRONT AVE
soLO: 163 FRON� �1� To: ST PACTL, Ni�
To: S T PAUL, MN 5 517.'7
5511?
cusr i.o.: S�HtTD�
P.O.NUMBEFI:
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• r 711.0000 711.00 E
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:3' 42" 9GA C�V 2 END POS�S. 1 CORNER
CI�ATN LINK FENCE, 37 .00 E
EOST� RFMOVE/HAUL RSrTAY OLD MA. ERIAL 37 .0000
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?�;RMTT 5T PAUL �qg.pp
E��',�A�,, BAI,AI3C 8/08/13 � � 3']�!.00
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�ypUNT. DUE..A�T PO5T. . E�� 374.00 .
�qT.Tt�iT DUE dN COMPL TXON
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su�ro�ra.: 7 4 8.04
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To'ra�.: '�Q S .0 0
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