Cass NOTICE OF CLAIM FORM to the City of Ssint Paui,Minnesota
Minnesota Stote StotLte 466.05 states tltat"...every person...who claims do�mges from ary mnnicipaliry...shaII cmrse to be presaiteid to the
govrrnin8 bodY of the nwnicipolity wid�in 180 days afrer d�e alleged bss or injury is discovered a notice stoting tlu time.ploce.and
cincumstances theraof,and the amount of co�rpensation or other relief de»mnded"
Pkase oompkte t�is form in its e�Y bY�Y h'P�6�'P��S Yonr answer to each qaestlon. If more sp�oe is
needed,atve6 ad�tional sheets. Pkase�te t�at yon wHl mt be contacted bY tdePhone to cl�answe�s,so providc as
ma�e6 infont�tion ss nc�ar9 tu c�lafi��ar ciaim,aod the ao�nt of eompe�ion bdng i'e4nested. Yoti wW reoefve�
written acknowl�t a�cs yoar form is reeeived. The process aa�taloe up to ten weel�or lon�er depa�di�on t6e
naturt of yoor daim. �is fo�m mo�t be si�ned,and bAth pages 000�leted. if somemiog does mt appty,wribe'IV/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL,SAIlVT PAUL,NIN 55102
�-�N� N�Ll�al as ����� A ,�N� - c�.s S
Company or Business Name N/Iq -C�I V E D
Are You aa Insurance Company? Yes/No If Yes,Claim Number? N� JAN 2 8 2014
s��� Z�S /�r�'�,�q�"on A��. inl�sb CiTY CLERK
�ty �t. F'G.� State �� Zip Code i�7
Daytime Phone�����- 34�$ Cell Phone���'7-34�$ EveningTelephone�)�7_ 3q��
Date of Accidard Inj ury or Date Discovered ��(���H Time i ;!1 �!pm
Please state,in ' what occuued(haPpeneci),and why you are submitting a claim.Please inc�icate why�how you
feel tl�City of S �its employees are involved and/ar responsible far your damages. �
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r�ea,e c�eck the box(e�s)that most closely represea[�lie ieason tor completing tbis iurm:
❑My vohicle was damaged in an accideait O My vehicle was damaged during a tow
O My vehicle was damaged by a pothole�condition of the street �My vehicle was damaged by a plow
�My vehicle was wrongfully towed and/or ticketed �I was injured on City P�P�Y
❑Other type of pmperty damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to inch�de oouies of all anulicabie do�ts.
For the claims types listed below,please be sure to iaclude the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be retumed and bacome the�xoPeitY of the City. You are encouraged to keep a
copy for yauself before submitting your claim form.
O Property damage claims to a vehicie:two estimates for the repairs to your vehicle if the damage exc:eeds
$500.00;or the actual bi1Ls ancUar receipts fa�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;ar the actual bills
and/or receipts for the repanrs;detailed list of damaged items
O Injury claims:medical bills,receipts
p photographs are always welcome to document and suppo;t your claim but will not be retumed.
Page 1 of 2—Please complete and retorn b�h pages of Clsim Form
Failt�re to compkte and retnrn both pag�.s wW r�sqit in delay in the handling of yom d�ian.
All Clsims—nka�e comdete this aec�ion
Were there wimesses to the incident? Yes �1,� Unknown (circle)
Provide their names,addresses and telephone numbers:
We�e the police�law enfarcement called? Yes � Unl�own (circIe)
If yes,what deputment or agency? Case#or rep�t#
iNhere did the accident�in�uty tak�e place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. Please be as detailed as 'ble. If sary,att�ch a d�agram.�� �'
s�d ' ri
Please indicate the amount you are seeking in compensafion o�what ou would like�e City to o resolve this claim
to your satisf�tion. �ot-
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Vehide cAm lete tl�s check box if this section dces not a 1
Yo�Vehicle: Year � Make '� Mode1 'C..."`ri �
Licease Plate Number U State�Colo �cowr�
Registered Owner
Driver of Vehicle ' '
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
�»,pa�_D������� '�check box if this section dces not auolv
How were you injured?
What part(s)of your body were injured?
Have you sought medical t�eatment? Yes No Planning to Seek Treatment(cincle)
When did you receive tre,ahnent? (p����(Sl)
Name of Medical Providet(s):
Address Telephone �
Did you miss work as a result of your injury? Yes No
When did you miss work? (Provide date(s))
Name of your Employer:
Address Telephone
�C!►eck here if you are attaching more pages to this claim form. Namber of additional pages � .
By segning this fon»,yor�are stati�g tliot all i�eforwiation you have provided is true and comect to the bcst
of your biowkdge Unsigne+d forms wiQ not h�e process�d
Submitting a false claim can resu�t in pmsecu�ion. Date form was compl�ed ����/ Z��`6
Print the Name of the Person who Completal this Form: N 1�0 4 S �s
Signature of Person Malring the G9sim: �,� �� (�9�--��
Revised Febivary 2011
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Sa�nt Paul Police impound lot, 830 Barge Channei Road, vehicle Release Form
Make:99 OLDSMOBILE License#:426MSY CN: 14011327 Invoice#: 26481
Dat�me Released:01/19J201413:33 Tow Charge: $ 123.95
Released to:TOSE Storage Charge: $ 0.00
Paid by.CREDIT CARD Admin Charge: $ 80•00
Reteased by.ANGIE � Tax:(7.625%) $ 15.55 �
I,the undersigned,have recovered the vehide described above. Subtotal: $ 219.50
I wiii check the vehide for damage or arry other problems that
may have ocxuRed while this vehide was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowiedge i will report
damage and/or any other probiems to the Impound Lot staff Totai Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/ar other problem:
Police Report made:Yes_No_IF Yes, CN � , If NO,Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMSIDAMAGE BEFORE LEAVING THE LOT
Signature �0�
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836 BAR(�(�IANFl Rp
SAINT PA11. IN. �187-245N
651-266-5642
►krctmnt ID: 8BB638B�1qq
Ten ID: 801739B9A6BgB638B1qq95
Sale
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DIS(X�ER Entr�Method: S�iped
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81�19i14 13.3�:31
Inv q; 9@9132 fl�r Code: 61961R I
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Vehide L.icense No. Ple�'�ear} �tais : i�ie � Type Mbclel Cobs 4
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'�B�tai�ei� ❑pwr�er 0 Aass�tger ❑Driver �
(�nse i+nr,�ion: � ,,• j��r. ,�. � '�:'��,�.,°r,:r`� ft-' f.�,�'..�_�``
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No 3 Offense �0'� _—
p Spe�d 169.14(N,M ): meh , mne �
❑No Seat Bett Use 169.686.1(a) �No Prod of>I�1�.791(2)
AC Taken—AC: Test type: ❑ Rei�d � B�eO�; '❑ 81ood ❑ Urine
❑Hazardous Maie�+at(DOI� ❑Uns�e Co�'itions , D Sctad 7_ex►e
p Endangering L�8 Praperty O Work Zone D Cammeraal Veh.DOT# !
Identification: �OL ❑DVS Web ❑Phol�ID ❑OU�r �
S�u bac;�of eit�t�ors foe irg���t�an paying your f€ne , —�
If cit�i for Pso Proof of Insurance or hb Driver's Licer�a n°�^ssession,Proof of Ir,��arce andtor �'
L?�vs�s L'+cense must 6�shown at one of the Violations �-aau focations fisted on tne ilack oi this {
citaUOn���°�'.hin 2S days from the date the citatF:,n+s filed with the Court. �
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