Rivera, NelsonRECEIVED
MAR 06 2(123
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota (, % T Y CL ERK
Minnesota State Smtute 466.05 stmes ttrat '...every person...who cbims darwges fmm ony municipality...shall cause to be presented to the governing body of themunlcipality within 180 days after the alleged loss or Injury is dis:avered a notrce stattng the time, place, ond circumstances thereof, and the amount of compensationor otherrelief demanded."
Please complete this form in Its entirety by clearly typlng or printing your answers to each question. If you have additional documentation you may add thosedocuments to your submisslon. You will not be contacted by telephone unlsss clarification is needed. The claim process for investigatlons can take upwards offour (4) weeks. Thls form must be slgned, dated with all applicable sections completed. Submission Is to the Saint Paul City Clerk's Office. You may email, fax(651-2664574) or mail the form. Mailing address Is "Salnt Paul City Clerk, IS West Kellogg Blvd., Suite 310, Saint Paul, MN 55102"
Company or Business Name:
lsthisclaimbeingmadebyanlnsuranceCompany? M@ lfyes,whatisyourClaim/FileNumber?:
Is this claim being made by an Attorney? '2hnrist'.-. i ut-" ii. If yes, what is your File Number?
If yes, then provide your lnsured's/ Client's Name
Street Address:
City:State Zip Code
Daytime/Work Phone Cell Phone
DateoflncidentorDateDiscovered(Mustcomplete) <;2/i7/g-bg3 Time 9a'3b &
Pleasestate,indetail,whathappenedthatpromptedyoutofileaNoticeofClaimForm. QAI,gJrSl;F'A)}Dfh.A?'jitz, "b'I:5
Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that willneed to be provided with your completed form. Photographs will be accepted. All documents submitted become the property ofthe City of Saint Paul and shall not be returned.
Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
€ Automobile damage from a street defect or pothole : please provide two estimates for repairs or adual bill that has been paid.
[utomobile was towed and may or may not have sustained damage: please provide copy of towing ticket (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 oractual bill that has been paid.
€ 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.
[1 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.
Isthereapolicereportforthisincident?!e@fyes,pleaseprovidethepolicereportcasenumber g3D27s381
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Where did the incident take place? Please provide a street address, intersection or name of City park or facility.
Notice of Claim Form, page two. Failure to complete and return both pages will result in delays.
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(:hs:?'7. 4pJsh5arsFor property damage claims, includin@ vehicle accidents.
LicensePlate# (-a) 974 313 Statevehicleisregisteredin rh'rirssa+aa
Registeredownerofvehicle Nzlssr> / Rt'wte- Driver "vrhes
WasthereCityinsigniaonthevehicle?0No Driver'sName (A4yl /e Jd>Alg?r@
Other property damaged:
For injury claims of any type.
What part of your body was injured?
First day of medical treatment?Are you still receiving medical treatment? Yes No
How much time have you mlssed from work?
If you are submitting other documents, please state what you are attaching and how many pages.
Bysigning this form, you agree that all information provided is true and correct to the best of yourknowledge.Please NOTE thatsubmitting a false ormisleading claim can and will result in pmsecution underMinnesota Statutes.
NameofPersoncompletingform: /V5/y 5 A'/-?'4'/'L-
Signature of Person submitting this form:
Relationship of person signing to Party making the claim:
Datedocumentisbeingsigned 3-(;-90@23
Revised December 2021