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Accm r <br />A~cident resulting ha in~'ury requiring medical attention or'hokt3italization to or death of any person, or total damages of <br />:S$~),00' or more shall be reported by the investigating 6fficerloperatOr on tliis form and forwarded' to' the M~NNESOTA <br />DEPARTMENT OF NATURAL RESOURCES, Division' bf Enfo~:cement, 500 Lafayette Road, St. Paul, MN 55155-4047 <br />within ten business days. - <br />QUESTIONS: 1-800-766-6000 METRo 296-6157 TDD Statewide 1-800-657'3929 ' TDD METRO 296-5484 <br /> Name <br /> o~' <br /> Person <br /> or <br /> Inve.stiga£mg <br /> Officer <br /> ,[ Telephone Number I D~ff~rtmen~ Name <br /> Address of investigating Department (No. & Street, RaCD, B.6x No., Ci.ty, Stat~'.Z!p Code) . <br /> <br />LDate of Accident [Time <br /> <br />j 'Description of Personal injuries <br /> <br />T_vpe 9f <br />cazsuatty <br /> <br />[--] Fatat ~ Non- <br /> Fatat <br /> <br />Property Coun. ty <br />[~:~'I Damage /~rto k ck <br /> <br />Owner's Full Name (First, Middle,'Last) I Address fNo. aZ Street. RFD. Box Na.. (v. itv .~tnta 7in ('cwt,=~ <br /> <br />ADULT OPERATOR <br />NON MUSA AREA <br /> <br />NON RESIDENT <br /> <br /> <br />