Leach, MatthewRECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Mtnnesota
MAR 06 2023
rnuniClpafit7 Within 180 DADS after the allegedl(m Orinjury /S diSCOVered 0 notice Staung the Ume, place, and CirCurnStanCeS thereof, and the amount Of COrnpenSatian
orotherrelrefdemanded.'
PleasecompletethisfomiinitsentiretybydearlytyplngorprlntingyouranswerstoeadiquaUon. tfyouhaveaddttionaldocumentationyoumayaddthose
documentstoyoursubmlssion. Youwlllnotbecontadedbytelephoneunlessdarffiationlsneeded. ThedalmprooessforinvesUgationsaintakeupwanlsof
four (4) Week. Thffi fonp must be signed, dated Wtth all appllfflble SectlOnS completed. Submlssion b to the Saint Paul . YOU ma'y , faX
(651-2664574) or mail the form. Mailing address is "Salnt Paul City Clerk, IS West Kellogg Blvd., Suke 310, Saint Paul, MN 55102"
IIE Aal-tIndividuals:FirstName MATTHGW Last Name
PleaselndicateYourPronouns: She/Her/Hers € He/Him/His@IThey/Them7Theirs €
Company or Business Name:
lsthisclaimbeingmadebyanlnsuranceCompany? NO If yes, what is your Claim/File Number?:
Is this claim being made by an Attorney? tsL O If yes, what is your File Number?
If yes, then provide your Insured's/ Client's Name
StreetAddress: J'i ';(a C,Q?1Q AM
City: 5'T'- 'f'AL&L State a4 ZipCode 5""
Daytime/WorkPhone b51-(p'5al - %"7 CellPhone Th(o3, &OI - 3'3Sr4
DateoflncidentorDateDiscovered(Mustcomplete) ' %r'- lo:'S nme S3'-55 M"f'oX)
Pleasestate,indetail,whathappenedthatpromptedyoutofileaNoticeofCIaimForm. %rf POT440'-el, ?%S 'nM
PleasestatewhyorhowyoufeeltheCityofSaintPaulisresponsibleforyourDamages? MA"A A('T@R'l 7"OT hk)"' l"a'
Please claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of
the City of Saint Paul and shall not be returned.
L) Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
JAutomuosb,,ileodaRm@aAgeofsro. mbLa .,tr,e,eti sdjefAevct(oar protahoble ,apl€easeFp%Tidre t, 2e)stimaltesbfo,r 5rThr actual bill that has been paid.
U Automobile was towed and may or may not have sustained damage: please provide copy oftowing tick<=t (if available), receipt
from Impound Lot, and two estimates for repairs or actual bill that has been paid.
€ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or
actual bill that has been paid,
[I Property damage: please provide two estimates for repairs or actual bill that has been paid.
€ You were injured during a motor vehicle accident: please provide police report number, details about injury.
€ You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury.
This section must be completed for all claims.
Is there a police report for this incident? Yes @If yes, please provide the police report case number 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.
5J%s7 A% T@AVatQ(, usb< Be-ruerar=i P/lso& AVE /IJ @ap wtt.oer< sl
Notice of Claim Form, page two. in delays.
Whatwouldyouliketoseehappentoresolvethisclaimtoyoursatisfaction? g(5'-l"6"ai5"MC5a"'(
ue*4R'( ua'A-C€'s lDyo 4 -sWere there witnesses to this incident? Please provide names and contad phone numbers. 3a ,4 4
For property damage claims, including vehicfe accidents.
Yourvehicle'sinformation:Year M Make 8(A'CXb Model l-AaRQ5SK Color Ra)
LicensePlate# ""J' izq Statevehicleisregisteredin aN
Registeredownerofvehicle .SARA,i-l e- LGaA('K Driver t'A$ 'F" c-Eke-au
Area(s)damaged F"" T)('!l'J'LG!'S 5106 -'il R)'5 ('C)%'C'TZD4EST)')
If a City vehicle was involved: License Plate # Color
Was there City insignia on the vehicle? Yes No Driver's Name
Other property damaged: No/'/'
For injury claims of any type.
What part of your body was injured?
Did you go to the emergency room or urgent care? Yes No Where?
Was medical treatment receiVed? Yes No Where?
First 4ay of medical treatment? Are you still receiying medical treatment? Yes No
Did you miss any work as result of this incident? Yes No Employer(s)
How much time have you missed from work?
If you are submttting other documents, please state whatyou are attaching and how many pages.
o thiS o istrueand thebest knowledge.
in MinnesotaStotutes.
Name of Person completing form: F
Signature of Person submitting this form:
RelationshipofpersonsigningtoPartymakingtheclaim: 5EJ-.F
Datedocumentisbeingsigned 5 MQ4')-02-'3
Revised December202l