Jernetle?, Joseph r��s�������o��� �`c��� �[f�€�� �La�fc� o� ��a€��� �a ���y af �a���� '�a�€�
/t�rnnesota Srate Statclte 466.05 /VOTICE OF CLAUI�...(EJve�y person...who clain�s damages from any
rriunicipality...shall cause to be presented to the governing body of the municipality within 180 days after the
alleged loss or injury is discovered a notice stating ihe time, place, and circumstances the�eof, and the amount of
compensation or other relief demanded.
Please complete this forr�� in its entirety by typing or printing your ans�tier to each q�es�ion i�t
tf�e space provided. If additional space is needed, please attach additional sheets.
�, � � � '�� - _
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PLEASE RETURN THIS Office af City Clerit
COMPLETED FORM T0: 170 City Hall ��� � 9 ����
�5 W ICellogg Blvd
St Paul Mf� 55102 �I�� ���:�"�►�
- . <. : t�j� .,�._ L, U ,1,,,�, -1 I i �
Your Name: - �� '"" a
Street Address: �.C, �i �• C t �"1_ _ 1-� 1.!� �' _ _ _ _
City: � �/`'� � State: � f v Zip Code: -s ���1 �
Daytime Telephone: (� �� ) ��U – G 6�C� Evening Telephone: ( )
Date of Accident o��d�nt: �2 �' � Day of Weelc: S`` � Time; a or m (circle one
� P �
Please state, in detail, wi�at occurred and the circumstances surrounding the event. Indicate how the
City of Saint P ul is involved, and why you feel the City is res onsible. � �.� � �
�-h� C �'� �rc� �.� f,. (� �aUe V��X'' i�r�,c�� �. ✓'� ^� ,�t�
, � �
—� . ,°c ��y -)� L, .n►Z/' �� /tit t( /l �-w�-�! , �j����_�l�"r S�-
+l` �V 0, �J"t�'11'1a� n-�-- -1 0 ' Gi_ � .
Please indicate your reason for completing this form:
L..l Veliicle accident (� Other property damage (piease provide specifics below)
� Vehicle was towed
L� Vef�icle ciamaged � Oti�er injury to person (please provide specifics below)
❑ Slipped and fell on City property ;�;
Please provide the names and telephone numbers of any City employees involved in this ��
incident/�{i�ent��d I�ow�tl�ey were involved:
� �
(over)
Ir` your vehicle v��as involved, ple2se complete the fpllo���ing: �� �
�' � 3
Year, mal<e, and model: �'�,,� (�. O��- � ��d��p�" License Plate I�lumber: ,
Exieni znd area damaged: �'��-�-r`� ('v�
\Nas a City vehicle involved in tliis accident/incident? Yes No (circle one)
if yes, please complete tl�e following: Type of vehicle
Year, mal<e, and model
Color of vehicle License Plate Number: -
Description of vel�icle
L_ocation of accident/incident (please ��rovide specifics sucf� as street address, intersection, cross streets,
park name, facility narr�e�; etc.):
�N s o;� c. «J ��..�
Please draw or attach a_cliagram if applicable:
_ . _
Please specify the nature and extent of the compensation or other relief you are requesting. Please
attach copies of any bills, receipts, ticl<ets, or other documents to support your claim. If you are
c.laiming damage to a vel�icle, please submit iwo estimates.
Were tl�ere witnesses to this accident/incident? es No (circle one)
If yes, please give t� names, addresses, and telephone numbers of th wi nes���`I' �
' � � �' 3 �
R s¢�� ✓ � ►� �� � s�, ,-, v N � �.��.,� � S � ° I
VVere the police called, Yes No (circle one If yes, what department or agency? � ��' `�--
Police report number: (3 2 � !� �� _
Please print the nan�e of the t
person completing this for�m; �� �� �� ��''�" �� �l
Pfea�e sign yo«r name: ;�!���� ` i.
� i
Date iorm signed: � �/� � � � D I � I
Risk �Agmt Di��ision - Revised 1 -30 01 � �
,i�:'�iji j�.
, ';`la;'l i':�;::
Saint Paui �alice lmpound Lat, �3Q Barge Ghanne! Road, Vehicle Ke�ease rorr�
Make 95 DODGE
l.icense#� 373LHR CN: 13231089 Invoice#: 147245
Date/Time Released: 1 C/29/2013 14:31
Tow Charge: $ 54.50
Released to: TOTNO Storage Charge: $ 0.00
Paid by: CASH Admin Charge: $ 80.�o
Reiea�ed b ' aRr�Y Tax: (7.625°/o) $ 10.26
y: �
I,th� unde�signed,have recovered the vehicie described above. Subtotal: $ 144.76
a wiil check the veh�cle for damage or any other problems that
;-n�y have occurre�while this vehicle was In the custody af the Service Charge: $ 0.00
Sa�nt Paul Pollce Gepartment. I acknowledge f will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 144.76
on th�s form priorto ieaving the impound iot. � N�r l � � �.� �
Damac�e and/or other problem:
:�� ,�.� �4,� �� �tiz �-o� �'��z° Fr,
Police Report made: Yes_No_IF Yes, CN
. If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMSIDAMAGE BEFORE LEAVING THE LOT
5�2ooe
Signature