Hero NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Stntute 466.05 states that "...every person...who clnims damnges from nny municipnlity...shall rnc�se to be presented m the
governing fiody of the municipaliry within 180 days nfter tlie a/leged loss or injury is discovered a notice stnting the time,place,and
circermstances thereof,and the amount of compensntion or other relief demnnded."
Please complete this form in its entirety by clearly typ�ng or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that yoa w�1 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 a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature 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 �e 1�/� Middle Initial�Last Name IVE D
.:.
Company or Business Name /��(�Ieae,�ti.vG JAN �
� 2�14
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address� 7 7 �RD��/4 V� i �/✓O� ��t.�r��
City S/� �R6L� . State�iN�NI�'SO��/ Zip Code_.;��
G�� Z g5 �2 96 Cell Pho Evening Telephone( ��rn�
Daytime Phone ( ) -
SuN ,p� � -
Date of Accident/Injury or Date Discovered `'� Time �0O am pm
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you � Q
feel the Cit o Saint Paul or its employees are'nvolved an r respo sible for y ur damages. � �• '
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P l e a s e c h e c k t he box(es)that mos closel y re present the reason for complering t is orm: ,�(„?
❑My vehicle was damaged in an accident ❑ My vehicle was damage d during a tow��� ��5
/
pJ�y_vehi��uas damaged by a pothole or condition af the street ❑My vehicle was damaged by aplow�o,y�.���
�My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ��a�����g
Other type of property damage—please specify �� rh/a� C/��/
❑ Other type of injury—please specify �I�s�i IpAU�
In order to process your claim ou need to include co ies of all a licable documents. pa qwp�/��rL�,
�twKS �-�iw
For the claims types listed below,please be sure to incluc�e the documents indicated or it will delay the handlin o
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 esti�nates if the damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list of da�aged 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 handGng of your claim.
Ali Claims—qlease comnlete this section
Were there witnesses to the incident? Yes No n�own (circle)
Provide their names, addresses and telephone numbe •
Were the police or law enforcement called?I� Yes No Unknown (circle)
If yes, whaC department or agency? /v Case#ar report#
Where did the accident or injury take place? Provide street address,cross street,intersection, nam of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amou t you are seeking in compensatio or what you would like th City to d to resolve th�s claim
to your satisfactiPn. /l��G,E — <
� � . �a .
-- - - ___ ____ �_ I� Z '- O t�
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_ ---- _ _ _ ------
Vehicle Claims— lease com lete this secti check box if this section does not a 1
Your Vehicle: Year Make Model �
License Plate Number Stat Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State lor
Driver of Vehicle(City E oyee's Name)
Area Damaged
In'ur Claims— lease com lete this sectio ❑ chec ox if this section does not a 1
How vuere you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes N Planning to eek 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 rlid�m��uark?,.___ rovi�e 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 this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed this Form: .
Signature of Person Making the Claim: `Q��
Revised February 2011
�`�� 1
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: HYUNDAI License#: 511 HDM CN: 14011327 Invoice#: 26522
Date/Time Released: 01/19/2014 17:38 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00 �
Paid by: CASH Admin Charge: $ 80.00 �
Released by: STACY 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: $ 00
Saint Paul Police Dep�rtm�nt,�l_ack�iQy+rtedge��vil�report - -
damage and/or any other problems to the impound Lat 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
Signature 5/2000
1 'Cz"O
St. Paul Police Department for
Ramsey District Court
RECEIPT
= Date/Time: 01/19/2014 17:38 Invoice #: 26522 :t
Vehicle Plate: 511 HDM/
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900642955 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CASH
KEEP THIS COPY FOR YOUR RECORDS