Hassan NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shal!cause to be presented to the
gove►ning body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by dearly 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 ea�plain your claim,and the amount of compensation being requested. Yoa 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�()1/lJ�[ �- Middle Initial Last Name f't�55�� n c��N E D
Company or Business Name �v��- �S �.�10�3
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address ��i �� S� - � � C I TY C L E R K
City �� � �(�-� L State � � Zip Code �.S b � .
Daytime Phone(��- -�1�C ll Phone(�/ .����ening Telephone(��2-) $o��°�
Date of Accident!Injury or Date Discovered � � ,�._Time � J am�m
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 aze involved and/or responsible for your damages.
i 1 1 /' .� /"') C ,
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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 of the street ❑My vehicle was damaged by a plow
❑ y vehicle was wrongfully towed and/or ticketed ❑I was injured on Cit propert �ti
ther type of property damage-please specify �l�i�-T ��-= 1�7����--� �� ����
Other type of injury-please specify � �
In order to process your claim you need to include copies of all aAplicable 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 aze 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
Accident Report Page 1 of 1
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Dilone Solutions, INC
Licensed and Insured
5300 76'� Place
Brookiyn Park, MN 55443 '
612-385-0607
dilonebalerasolutions@hotmail.com
Proposal for Cement Footing
,�
Address: S ���E �z u S A �-i�- � �-}'' s-� .� �� P,��� ,�,� ;-� i��
Descrip#ion of Job: Cement Footing
Make new 42 inch (deep) by 12 inch (wide� footing for new light
post. Instail new post and light1
Totai: $4,795
Clients Signature
Dilone B dera
Dilone Solutions, Inc
Upon signing this confroct and returning it to Dilone Solutions, Inc; you are
agreeing to pay the above amount upon the described work being
completed. The price of this proposal is valid for 30 days.
We are usually able to start jobs within 48 hours of receiving a signed
coniract. Please call the number obove to schedule the above work once
contract is signed.