Scan2022-04-08_121845_001 Revised December 2021
If yes, what law enforcement agency responded?__�______________ _ —_—_--_--__
Where did the incident take place?Please provide a street address, intersection or name of City park or facility.
Notice of Claim Form,pagetwo. Failure to complete and return both pageswiU result in delays.
W t would you I�e to see h pen to resolve this clai to your satisfaction? WQU�� I��_��'���� �/
�r w�y -�Y2. r.e p�-v�cv� �v�-.�-o-,� �t� Po�T�,d%�-t� �c ��v� c�.���e._'C•
Were there witnesses to this mcident? Please provide names and contact phone numbers. ___ ____________—_
For propertv dama�e claims includin� vehicle accidents.
Your vehicle's information: Year�b�-�_Make_C1�1(�QL'�.`�__Model SI 1�41��S�v_Color���a�__
License Plate#���__9QZ�____State vehicle is registered in___��_________
Registeredownerofvehicle_���V �__ ______Driver__�.0�,�„�GI,__ _______�_—
`,, � � �
Area(s)damaged _��Vl��G1'�_!'��1�__�G�(J�_�.�'�------- ----
If a City vehiclewas involved:License Plate #________`_____________ Color_____ ____,_�____
Was there City insignia an the vehicle? Yes No Driver's Name ___�_______ ____ _�--�__
Other propertydamaged: ---------
For iniury claims of anv tvae.
What part of your body was injured?_____�Y��.,�______________—___—�—_�—_---�--
Did you go to the emergency room or urgent care? Yes No Where?__�I _____ _—_—._�—
�---------
Was medical treatment received?Yes No Where?___���__,____ ______—_ _--_-----
First day of inedical treatment? _��__Are you still receiving medical treatment? Yes No �
Qid you miss any work as result of this incident? Yes No Employer(s) ____ N _�____,—_
�-------
How much time have you missed from work?__�____� 't°� —
�-------------------------
If you are submitting other documents, please state what you are attaching and how many pages.__________ ___
By signing this form,you agree that all information provided is true and correct to the hest of your knvwledge.
Ptease NOTE that submitting a false or misleading claim can and wi11 result in prosecution underMinnesota Siatutes.
Name of Person completing form:__�.����'�' __ ___—__—_—_
�
Signature of Person submitting this form: _ _ ________—__—__—__---�
Relationship of persan signing to Party making the claim: ______ _____
Date document is being signed_�����"�
Revised December 2021