Stanford NO�'� OF CLAIM I'ORM to the City of Saint Paul, Minnesota
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4lirrrresotn Swte Stutute 466.05 stntes�hat "...eveiy person...tii�ho clni�r�s dnmages fi-rnn any municipnlitv...shall cnuse tn be pre��e»!ed!o�he
���,��i�ir�g�`n���'�tlte munrcipnlity mi�hin 1 RD dcrvs n/'icr d�e nlle�ec�/oss or ntjury is dLscovered n notice stnting the�ime,place,und
� circumstn��ces tltereof,and the c�mntu�t q/'compensatinn or other relief demnnded."
V►��s�cchr►�te�te"t�f.s form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note th:it you will not be contacted by telephone to clarify answcrs,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or lon�er depending on the
nature of your claim. This f'orm must be signed,and both pa�es completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
'�� � (� N Middle Initial �Last N�me � �� ��'/2-�
First Name �,!,i�
Company or Business Name RF�'�IVED
Are You �n insurance Company? Yes/No If Yes, Claim Number? IA�1 � O 2�'�
Street Address_ "l��L� ���%��°��(1_ �/�-�L�-� ��— 6� "°� �r.■-.-.. .�.��
City����)yo-t�%% ��i.-`��-`i; State ���1/`-J Zip Code �J���7
Daytime Phone ;�)��L Cell Phone ( ) - Evening Telephone (�)�>`1 7- 3 2�-��
Date of Accident/ Injury or Date Discovered / ,-� �'� / � Time � � � �a /pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
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Ple�ise check the box(es) that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street � My vehicle was damaged by a plow
�S,I My vehicle was wrongfiilly towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
• ❑ Other type of injury—please specify
In order to process your claim you need to include copies of all anplicable documents.
For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills, receipts �
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
I�'ailure to complete and return both pages will result in delav in the handling of yuur cluim.
All Claims-�lease comn�ete this section
Were there witnesses to the incident'? es No Unknoun Icircle)
Provide their n• mes, addresses and telephone bers:
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Were the police or law enforcement called'' Y� No l,�nknu�►n � Irircle)
If yes, what department or agency? Ca,e #ur report # �' � ��'C - �''�y
Where did the accident or injury take place? Provide street address,cross street, intersection, name uf park e�r facilit�.
closest landmark, etc. Please be as detailed as possible. If necessary, attarh a dia�ram.
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Please indicate the amount you are seeking in compensation or what you �soul� like the City to do tu re�ol�e lhl>CI�InI
to your satisfaction.
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Vehicle Claims-please complete this section ❑ check bc�x if this serticm �ic�s nex a�l�
Your Vehicle: Year ��;� �( Make DGn �� � ��z� �; �j=;-�
License Plate Number ��' k � State �'Color = �L ,;' z /'�
Registered Owner �E> S <}-�- L� 2-
Driver of Vehicle �i�-�- . 1'/'-�-�r_��ti-�.
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injury Claims-please complete this section O �herk b�i� if thiti �ertion �iu�, n��t a�l�
How were you injured`?
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What part(s) of your body were injured? ��
Have you sought medical treatment? Yes, No Plannim� tu Seek Treatment (circle)
When did you receive treatment? `� (provide date(s)1
Name of Medical Provider(s): '
Address Telephone
Did you miss work as a result of your injury'' Yes No
When did you miss work? ��,�����������i��,
Name of your Employer:
Address ��� Telephone __
❑ Check here if you are attaching more pages to this claim form. \umber of additiunal pa��s
By signing this form,yor� are stating t/tat all information yor� have pro►�ided is true and eorrect to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed i-� l�� �; �
Print the Name of the Person who Completed this Form: /�-����� �� °-" ��_�
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Signature of'Person Making the Claim: ;,C��-�,
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Revised February 201 I �
rme�ontractor c,a��ed rme oontractor Amved SAINT PAUL POLICE DEPARTMENT �
p o�S TOWED VEHICLE REPORT
Day Month Date Year Time Squad District Towi Contractor
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Locatbn of Call Locatbn of Tow/Reoovery Time 8 Date Occurted or Between Hows Class
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Victim last First Middle Address
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If Stolen,MetFwd Used Ignitlon Locked Auto Key in Auto LocaUon of Key �
purxhed� Jumper Wire� Key� Other� Yes No� Yes� No ,
Inventory of Properly Lett in Vehicle
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Disposilion of Property It Removed From Veh�le Lab Ma�ysis Desired
Cr{me Lab� Crime Lab Locker � PropeRy Raom� Other � Fingerprinting� PhotographiC� SeerCh� Odter(Explaln)�
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p,.r�,�,�y� gy Whorn te Vehicle Released By Wtwm Oate RebNe PM+mber Ve�tide Tag No. �.
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Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form ��
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Make: 11 DODGE License#: 584HXY CN: 13266844 Invoice#: 148199 ti �„ t
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Date/Time Released: 12/16/2013 15:13 Tow Charge: $ 54.50 � RU
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Released to: OWNER Storage Charge: $ 0.00 �1 ��,
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Paid by: CASH Admin Chargee $ 80.00 �
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Released by: PERLITA Tax: (7.625%) $ 10.26 � ,;'�
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I,the undersigned,have recovered the vehicle described above. Subtotai: $ 144.76 �
I will check the vehicie for damage or any other probiems 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 probiems to the Impound Lot staff Total Charges; $ 144.76 �
on this form prior to leaving the impound lot. �
Damage and/or other problem: �
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Police Report made: Yes_No_IF Yes. CN , If NO, Why? �
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000
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