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Hanson, HeatherNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that n ••. every person ... wha claims damages from any municipality ... shall cause to be presented to the governing body of the municipality within 180days after the alleged loss or injury is discovered a notice stating the time, pkxe, and drcumstances thereof, and the amount of compensation or other relief demanded. N Please complete this form in its entirety by dearly typing or printingyour answers to each question.Ifyou haveadditional dorumentatio n,you may add those documents to yoursubmission.You will not be contacted by telephone unless clarification is needed.The daim processfor investigations can take upwardsoffour (4) weeks.This form must be signed,dated with all applicablesections completed.Submission this completedform to the Saint Pau I City Clerk's Office by email (cit-,clerk@ci.stpaul.mn.us),fax (651-266-8574)a mail addressed to "Saint Paul CityOerk,15 West Kellogg Blvd.,Suite 310,Saint Paul,MN 55102". Claimant:First Name:~ea i],e,( LastName:~-+~~-S)~~Q_,....._ Please Indicate Your Pronouns:pshe/Her/Hers,□He/Him/His,□They/Them/Theirs Company or Business Name:----------------------------------------- Is this claim being made by an Insurance Company?YES © If yes,what is your Claim/File Number?_ Is this claim being made by an Attorney?YES /JI§) If yes,what is your File Number?_ If yes,provide your lnsured's/Client's Name:----------------------------------- StreetAddress:43l}C))Qr le.5 ,Aw City~PCUJJ Daytime/Work Phone:l.Q5 J ~ 15 Z)'5£J} 2 _______State:M \\\ Zip Code:D 5 { 03 Cell Phone:_ Date of Incident or Date Discovered (Must Complete):~)~1,l,-0~8"-+l-2~3~ Time: B'. 00 A\1 Pl1ase state,i~_s!ail,_wpat happened that prompted you to file a Notice of Claim Form:\J\e,Q.hon t C,, dh.J-e.d ~ e~ ':1f'OrY\ ~ h&-tQ..S ,· _J_ • }-\,... I \ Please state why or how you feel the City of Saint Paul is responsible for your Damages?lA \ ~ U\» ~l IL\ 15 1JlSfP'1:sLVJl.d< +o Yr\.~ th~ ctr~ -u - Please check the reason that most closely describes the reason for your submitting a 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. □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 actual bill that has been paid. □Automobile was towed and may or may not have sustained damage:please provide copy chowing 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 or actual 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. □You were injured in the City of Saint Paul:please provide police report number,witnesses,and details about injury. Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays. Revised March 2023 Th is 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:_ If yes,what law enforcement agency responded?_ What ._,,ou d you like to see happen to resolve this claim to your satisfaction?r....t Were there witnesses to this incident?Please provide names and contact phone numbers:f--1 /-A._ For property damage claims, including vehicle accidents. Your vehicle's information:Year:2D l 2.Make:e.J,.e.,v½ Model:I rn.~ Color:Ba~~'"' License Plate#:H R-t\ZJ L State vehicle is registered in:'-fY\ U')J}i ~O,,J Registered owner of vehicle:i-\ro.t::J'.ut: t\:Cln{:f:()Driver:-~-·Q.ffil~~~------------ Area(s)damaged:..:$,UsG1°'9.J161 DVl If a City vehicle was involved,License Plate#:Color:_ Was there City insignia on the vehicle?YES/NO Driver's Name:_ Other property damaged:~~.......~----------------------------------- For injury claims of any type. What part of your body was injured?__.N--=-+fBi_;_ _ Did you go to the emergency room or urgent care?YES/NO Where?__._N--=-1...f\.c..c.. _ Was medical treatment received?YES/€)Where?_ First day of medical treatment?-.~£?~ Are you still receiving medical treatment?YES/NO Did you miss any work as result of this incident?YES i@ Employer(s):------------------------------------------ How much time have you missed from work?_,___ If you are submitting other documents, please state what you are attaching and how many pages: 2- J6-h_"rna,t<-, ~ ~C..\~ ~OY V' JL{)O. l rs By signing this form,you agree that all information provided is true and correct to the best of your knowledge. Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes. Name of Person completing form::±\fOv-til~~ Signature of Person subrnitting this focm,f----/~!_ ~_¼_i~~~------------------- Relationship of person signing to Party making the claim:-&k/;----++----------------- Date document is being signed:///J 8 I 23 I Revised March 2023 I RADIATORS /COMPRESSORS /CONDENSERS /FUEL PUMPS A/C KITS/HEAVY DUTY RADIATORS •OEM QUALITY/FIT •LIFETIME WARRANTY • OPEN SATURDAYS •LARGEST INVENTORY IN NORTH AMERICA -~ ll Remington Auto Repair,Inc.NAME \-\r Mi t\b /l.. II- I ij1152RiceSt ADDRESS t 1 St. Paul, MN 55117 i,~.• I If I '~· 651-489-7971 CITY Df\:_tl?- /5 I GUST.ORDER NO.I WHEN PROMISED I p~1S-8St,~ AMT PART No.NAME OF PART SALE 'O'-'- AMT.YEAR AND MAKE OF CAR -TYPE OR MODEL I SERIAL NO. ' S.JA y 6Ni(1\ ?- ~, \ 2/J~.l L. tf1 \~ I ,?.. L1.1 ~I MOTOR NO. \f· .. ~\ \ . ' ivbt uO 5~ "f /LIC.ENS~NO..z!i , MILEAGE WRITTEN BY'" Ou el{,~fhZ1 ,7 1 1 ~j ~d P:6.1 \ll\\-::::,l3,,!Q.94.1b to~ I~ DESCRIPTION OF WORK AMOUNT '-- - 3~~1,. ~ ", 4-4_(._ ~4rA~S~---1 \sA2.i . ~ .ll Lt 1S .-1..~ ••r' t ~- ,,.., --~! \ t,-'(~ ~-; tbv1~• ~ ,._ c~~. Eu11J t- ,... ....... ,. (.,(... .. ~'). I) ,II 'I - "', -....,.~ . If l- -~~ 'r?Ctt:t- St..e., Mi ,~, ~ L~,,q:s \O'J C ct', ·i I'"'(\ ,I I[)V_JJ rJtGi);~ 1f! ~-u- L ~v\l. 1'7\,~ ~.~ ?\~ -'IL.I II h)it\~, v '\\) C.,'("'. l pr, a GAS,OIL,GREASE !:;HEQK BELQW LABOR ONLYLUBRICATE •CHANGE 3~:, 12 GALS.GAS ENGINE OIL PARTS I\ TC TAL PARTS +QTS.OIL TRANSMISSION ACCESSORIES I LBS.GREASE JC ACCESSORIES, TIRES AND LUBES DIFFERENTIAL EPAI I --WASH ss 1r•1r SUBLETPOLISHREPAIRS TOTAL GAS +TOTAL +TAX 1 '- --- OIL AND GREASE ,SERVICE -,L AUTHORIZED BY I I~:)L2TOTALACCESSORIES+I ~TOTAL+j ,(:) ESTIMATES ARE FOR LABOR ONLY,MATERIAL ADDITIONAL I hereby authorize the above repair work to be done with necessary materials.You and your employees may operate above vehicle for purposes of testing,inspection,or delivery at m~risk.An expressed mechanics lien is acknowledged on above vehicle to secure the amount of repairs thereto.It is understood that this company assumes no responsibility for loss or damage by theft or fire to vehicles placed with them for storage,sale,repair or while road testing. PAYTHIS ,+. AMOUNT J.•.., -·.I.-,_..