Rogers Winston NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims da►nages fro�n any municipaliry...shnll cnuse to be presented to the
governing bocly of the municipaliry within 180 days nfter the nlleged loss or injury is discovered a notice stnting the tin�e,p/uce,cmd
circumstances thereof,and the amount of compensntion or other relief demnnded."
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, AINT PAUL, M 55102
First NameC�Y,�A �`� Middle Initial� Last Name � v
Company or Business Name
RECEIVED
Are You an Insurance Company? Yes No If Yes, Claim Number? SEP 3 0 2013
Street A dr s �� � ' K
City State Zip Code__��L�L��
Daytime Phone( ) - Cell Phone�l a�-0!`-� IL�ening Telephone( ) -
Date of Accident/Injury or Date Discovered��\,,��•-1----" Time � a pm
Please state,in detail, what occurred (happened),and why you are submitting a claim. Please indicate why or how you
feel the City`qf Saint aul o�its employees are involved andlor respon 'ble for your da ges.
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Pl�ase check the box(e$)that most closely represent the reason for completing�i s orm.
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
fl N1y vehicle�vas damaged by a pothole or condition of the street My vehicle was damaged by a plow
�My vehicle was wrongfully towed and/or ticketed �� was inj on ity propeRy (� '
Other type of property damage-please specify 1:��e�
❑ Other type of injury—please specify
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
�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
�Photo raphs are a�eys we comelto�docume�n�a�nd u �o�ur claim but will not be returned.
e` 1'� `r i � rn�'ioth a es of Claim Form
Pa�I of 2 �le3se com�et�and retu
\� g P P g
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease comalete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Pfqr�id' their na es, addresses and telephone mbers:
v► q
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 la ? Provide street address,cross street, intersection, name of park or facility,
closest landmark, etc. Please be as d aile as possible. If necessary, attach a diagram.
Please indicate the amount you are ' g in compensation or what you wou d e the City to do to resolve this claim
to your satisfaction. �
Vehicle Claims— lease com e this section ❑ c eck b x i this se tion does not a 1
Your Vehicle: Year e Model
License Plate Numbe 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 N me)
Area Damaged
In'ur Claims— lease com lete this section ❑ check box if this section does not a I ,
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Pla ning 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? (grovide date(s))
Name of your Employer:
Address Telephone
���Check here if you are attaching more pages to this claim form. Number of additional pa
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 �
1�
Print the Name of the Person who Completed t F _ —
Signature of Person Making the Claim: —
Revised February 201 1
Sai�� �'��ii Cit�� �ouncii � �� �'3
�ublic Hearing l�Iotice .�I
Ratification of Assessment
COUNCIL DISTRICT #
YLANNING DISTRICT#
FILE#Jl3I2A
Darryf Do ASSESSMEI�IT#138535
PRnPERTY ADDRES�
35 STEVENS ST W
PARCEL ID
07-28-22-14-a056
PROPEK'I'Y T'AX DESCRIPTION
WCST ST PAUi.BLKS 1 THRI l 99 F.X�t'aO iT GOT (+RLK 99
Plcase return the GOLD card within 5 davs if vou wish to be heard bv the I�iearine Officer
LEGISLATIVE TIMC: '[luesdny,Au�vst 2Q,2013 at 9:Q0 AM
HEARING PLACE: Room 33Q,Third Floor,City Hall-Court House, 15 W Kello��Blvd
An ins��ector wiil be prescnt at tl�is hearitt�t�►r•enort on whnt uccurred at vuur
prOperty.
THE TIM}?: Wed�iesday,Uctober O2,2013 at 5:30 PNI
PUBLIC PLACE:City Council Chambers,3rd FL CitF Hail-Court House, 15 W KeIIogg Blvd '
HEARING Oral or�crritten statements from an owner wiil be considered by the Council as a furthcr
appeal after firsi attending the Legis{ative Hearing.
PURPOSE 'Co consider approvai of the assessment for:
Property Clean Up on Private Property during the time period of June 5 to July 1,2013
ASSESSNIEN7' If thc City Council approves the file,the proposed assessment will be assessed against
INFORMATION the property. Thc ESTIMATED assessment for the abov2 property is�448.00.
NOTE: THIS 1S NOT A BILL!
Please see PAYMENT INFORMATION on the reverse side of this notice.
ASSGSSMEI�IT Summary Abatement 288.00 X 1.00 ° $2g8•�
CALCULATtON DS!Admin Fcc 120.00 x t.00 - ��20-�
Real Estatc Admin E�cc 1.W X 35.00 $35.00
Au�,mev Fce i.W X 5.00 = 55.00
.
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lnvoice wil{t�e sent to the taxpayer �
CONTIMJED ON RE�'��KSE 51DF N01'[P[CATION DATL O8!01/2013
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