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Guluma • • �OTICE OF CLAIM FORM to the City of Saint Paul, Minnesota � ..�,:a Snne Strrnrte=166.0?.cta�es thu� " ...ei erv pe�:ti�on...i�i�;�o cluina.e dnnaa,;es T•an any nliu�icrpaliry...shnll catrse to be presented ru!he ;�,��°rni�?;ho�lr ofthe n�rn�rciprrlrt�;ivilhi�� 180 days nler Ih�>alle�;ed lo.cs or inj�uy is drscovered n nolice srutr»o lhe lin�e.pinc�. nnd circums7ances�hereo/,and tlre anrorrnt of con�pei�sation or othc r relief demanded.. Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed, attach additionat sheets. Please note that you may or may not be contacted by telephone to discuss your claim circumstances,so provide as much information as necessary to explain youl•claim,and the amount of compensation being requested. This form must be signed, and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 F��-st �al��e ��i � - � �� V�, � RECEIVED =��r��1 Middle Initial Last Name_ •S 1 1 � 1 Company or Business Name, if applicable dEC 2� 2��3 street .-�ddi-ess 1(�• 2 �► F��,�� k1►eC�1��-� ;� CITY CLERK City��T `�_�� State�_�� Zip Code � � � ' �. Daytime Telephone (�_)�"z� _ �,-�-� Evening Telephone (��) `) �� _ ��,� —� .�= ,��-�-- Date of Accident% Injur-y or Date Discovered E� �' 4�� ) f- ` �Z Time �• ` � am � pm (circle) . _ Please state. in detail, what occur7•ed, and why you are submitting a claim. Please indicate why or how you feei.c�`�Citv of Saint Paul or its employees are involved and/or responsible. c ti ' ( . ., ' � ` ,. . ��yv1�u'�i� �1� �� .� � � S �.��."�t V'__l L__��,�" �11c-�(1 .- .."r1� •tr. ^ ,�. � ti'', ,�1� �� - ') � — •�- , '� � �� w..J_C�• C")i c, �C�t l=1a.i�� i�: �y� 2 v` �\ y` C ` " ` \ �,�:,, , ,, � ,.�'_.Rn� ��4� `► ��,4�; c � ' � � ' L: L � u � h ° , ` - � 1 ' �\ c,`� 1, y� ' � �A�d'�1CAs:. �r�-�=��,�� 5'�L�i.�p a �^'�-�;,� ��C�,ti� Please check the box(es) that most cYosely represent the reas�r completing this foi�n: ❑ Vehicle was damaged in an accident �l Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ❑ Vehicle was wrongfi.zlly towed and/or ticketed ❑ Injured on City property ❑ Other type of property damage—please specify ❑ Other-type of injury— please specify ❑ Other type not listed—please specify In order to process your claim you need to include copies of all aqalicable documents This is a t�eneral ��uideline of what should be submitted with a claiin form, but it is not all inclusive. You inav be asked to pro�ide additional infot�nation depending on your claim. O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts O Other property damage: repair estimates, detailed list of damaged items O Injury claims: medical bills, receipts O Photo�-aphs can be provided but will not be returned. Page 1 of 2 — Please complete and return both pages of Claim Form Failure to provide a completed claim form will result in delays in processing. . Notice of Claim Form, City of Saint Paul, page two All Claims — lease com lete this section "-� �� ei-e there witnesses to the incident? Yes � No Unknown (circle) It�e�. please provide their names, addresses d tele hone numbers: ' ' �� I�—�G+ �— v ' �— � T�.� 'o � � ��I�;-� (, � � —��=�— �-0 6 � �� ere the police or law enforcement called? Yes No Unknown (circle) If�es, what department or agency? Case# or report # Where did the accident or injury take place? Provide street address, cross street, intersection, name of park or facility, closest landmark, etc. Please be as detailed as possible. If helpful, attach a diagram. �� t`� c: r 1 � �ti '— 9 Please indicate the amount you are seeking in compensation fi-om this claim or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims - please complete this section ❑ check box if this section does not applv Youi Vehicle: Year �f�`� S Make C'1c��_Model_�� LicensePlateNumber��. State�Color � �`til��Pr Registered Owner �r ri�T�[ = {f 1,j � �-�J ( ] �1� Di-i��er of Vehicle � ��"j'�� '��J��_ Ai-ea Damaged �„L`l��-�--�,�F (�Ll�liltla,� ��_C�`,'�� e v- ��t� �"ehicle: Year Make Model`�a License Plate Number State Color Driver of Vehicle (City Employee's Name) -�rea Damaged Iniur� Claims — please comnlete this section � check box if this section does not applv Ho�ti «ere you m�ured? ��hat part(s) of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) Wllen did you receive treatment? (provide date(s)) ?�'ame of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) '�ame of youz- Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages g� s!:ning�hrs form, I'ou n�•c slating thrrt ull informntion you hnve p�•ovrded is ti•ue und correct to the bes�ojyour knowledge. C nsig�red /br�ns tiri/l not be processed. Submiding u fulse c/aim can resu[l in pro.recerrion. Print the �ame of the Person who Completed is Form: — }� Signature of Person Making the Claim: � , - Date form was completed�(�(� ,_'��j ',� l�� e rt��;s�d A�„-;i ?oo� i�,�67 � s+evP T�w . �� 2 � .3-3� SRGo � �-�1n � � � �,� � --- � � .� I 1� �b1 � Saint Fuu� , ...._ arge Channel Road, Vehicle Release Form Make: CADILLAC License#: 891 DCL CN: 13267540 Invoice #: 23418 Date/Time Released: 12/18/2013 18:16 Tow Charge: $ 123.95 ,,� °' �' �:4� Released to: TOTO Storage Charge: $ 0.00 �, Paid by: CREDIT CARD Admin Charge: $ 80.00 Released by: LEE Tax: (7.625%) $ 15.55 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50 I will check the vehicle for damage or any other problems that may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 Saint Paul Police Department. I acknowledge I will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50 on this form prior to leaving the impound lot. Damage and/or other problem: �- �� -� � �� .� `t.a.- +�� ,,.,,..:i ;.i_I.��.t- n1- �/"S..e [jY b� t�.�dl �' �I i✓t V�.'��}_,:t�--� 1+� /+�Qy��at I. U rl"'�' ��`-1� C�d�vt�c�, Police Report made: Yes ��f�lo_IF Yes, CN , If NO, Why? TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature si2000 �� /� ; �--- ___—�/ � Saint P iarge Channel Road, Vehicle Release Form s� rRU� 1fIPOUNL �oT MaICB: 8'6 BARGt CHAfINEI RD �91 DCL CN: 13267540 Invoice#: 23418 SFtIHT PAUL MN. 5510i-�245u 651-'266-5642 Date�Tirr Mercliant. IG: d1�4]6380144 Tow Charge: $ 123.95 r°'" "' rr��. io: �eira�a��as��e3auiauab �r � f Releasec $ale Storage Charge: $ 0.00 � �J Paid by: � zzzzzzzzzzzz4089 Admin Charge: $ 80.00 � hASiERCARD Entry Method: Saiped Releasec Amount; $ 219,50 Tax: (7.625%) $ 15.55 iaz: $ 0.�1 I,the und� -°__-----'------ described above. Subtotal: $ 219.50 __ I will chec Total: � 219�50 er problems that may havE 12�18�13 18;20;38 he custody of the Service Charge: $ 0.00 Saint Pa� Iov �; 0�4021 Appr Code: 148496 ' I will report damage � p�rvd: �nllne �ound Lot staff Total Charges: $ 219.50 on this fo� Customer CoPY Damage i THANK Y�U! d-k'�L �-�. �!-/Vq 9� <r� �� y� � r � �"�� Q �`"� ��5!' S/ � � `�� olice Report made: Yes_ o_ IF Yes, CN , If NO> Why? TO PROTECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature 5i2000 ; i � , � i �_` ------�