Walker, Ariel NOTICE OF CLAIM FORM to the City of 5aint Paul, Minnesota
Minneso�n Stnte Stntute 466.05 stnte.r that "...every persnn...who clni►ns dnmages fran any municipaliry...shall cnuse to be prese►rted to dTe
governing��ody of!lte mctnicipnlity widtin 180 dnYS nfter dte ctllegetf loss or injtrry is discovered a notice stating tlre trnte,p(ace,nnd
circwnstnnces thereof,and the nmount of compensntion or other relief demnnded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note thlt you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive�
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nah�re of your claim. 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
First Name ��� i � 1 Middle Initial � Last Name ��Ui,1 K.-�, ►. �C�`G'i\/�I'°q
Company or Business Name
Are You an Insurance Company? Yes/(Nc� If Yes,Claim Number?
Street Address I C��-6'l� -��`-��� `�� �� L
cc- '�
City`���r��r--�\ �r�C'�L�� State 1M`"V ZipCode-�� J{�
Daytime Phone (�.)Z?,r�-'Z��\n�lCell Phone ( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered ����� ��1��?� Time �� ` C1rii�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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Please check the box(es)that most closely represent e reasodfor 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�f the street ❑ My vehicle was damaged by��}v.C I` �E�
�My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City prope y ��C V
❑ Other type of property damage—please specify ►
❑ Other type of injury—please specify AN 2� Z0�^�
In order to process your claim you need to include copies of all apnlicable docume�ITY CLE�K
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
1nd/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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section .�°
Were there witnesses to the incident? Yes No ` Unknown , (circle)
Provide their names, addresses and telephone numbers: - �
Were the police or law enforcement called? Yes �N� Unknown (circle)
If yes, 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 necessary, attach a diagram. A��1
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�21 �Y � `
Vehicle Claims-please complete this section ❑ check box if this section does not applv
Your Vehicle: Year �� Mak��»� �c��.. Model �ta r�c.l Pv`
License Plate Number � •�� �- StateM� Color �'v h�-� _
Registered Owner �C i� \ �l'���i 1t�:✓
Driver of Vehicle �� �� t �l:C�1.�:�y'
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims-nlease complete this section ❑check box if this section does not apply
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name 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))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing tliis form,yocc are stating tlaat all information you laave provided is trzce and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecutiore. Date f'orm was completed � - L a�` Z C7� �
Print the Name of the Person who Completed this Form: ��' t z L �:L��•�\l��,,,a,
Signature of Person Making the Claim:�`�--�t=�_x :, b C��,�1.�;.� i,-�
Revised February 201]
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: License#: 880�YL CN: 13267540 Invoice#: 23222
Date/Time Released: 12/18/2013 16:04 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00 �
Tax: 7.625% $ 15.55 �
Released by: AMANDA � )
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:
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/200�
Signature
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CITY CLERK