Weber REC�IV�I�
FEB 04 201�
� � NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��y�s�t�����
:1.fr�rnesn��r S�arc Strrrure 466.0 i.s�nies rhnr ' ...e��ery person...i-�l�o cluinrs dnn�n�qes.�'om nny mtu�icipnlity...shn1!cnuse to be prescn�ed ru�he
,,orcrnrn,�hodj-nf the na�micrpnlrt�;ivNhin 180 days nfier�I�e nlle;ed loss or injury is discover-ed n nolrce stnun,o�he�ime,place. nnd
crrcunu7nnces thereof, cmd the mno�uit orcornperrsnlinn or other relief demanded."
Please complete this form in its entirety b,y clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you may or may not be contacted by telephone to discuss yoar claim
circumstances,so provide as much information as necessary to explain your 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
Y_...
First Name - '��,�, Middle Initial � Last Name i,��b��
Company or Business Naine, if applicable
Street Address j ���j ��,�`a,t�. � �v' ,
City_��� ��,� State /��lnln��c3Tu Zip Code I G '�
Daytime Telephone (b�l ) 0([;5 - ZC�(4. Evening Telephone (0. l ) -(�4T, - 4��2
Date of Accident/ Injury or Date Discovered l�:.� � �j"�C3 �?j Time �' 4Z am /�m circle)
�s
Please state, in detail, what occurred, 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.
� _ i , '� ' I/LC
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Please check the box(es) that most closely represent the reason for corr�'eting this fonn:
❑ Vehicle was damaged in an accident O�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 wrongfully 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 youu need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claiin form, but it is not all inclusive. You inay be asked to
provide additional infonnation 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 claiins: legible copies of any tickets issued and copies of the impound lot receipts
O Other property dainage: 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 — please complete this section �
Were there witnesses to the incident? Yes No ' Unknown (circle)
If yes, please provide their names, addresses and tele umbers:
Were the police or law enforcement called? Yes No Unknown (circle)
lf 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
o facility, closest landmark, etc. Please be as detailed as ossible. If helpful, attach� diagram.
` ' Q:t/P.V�U� v� '� UIC�e
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Pleas ndicate the amount you at-e seeking in co�pensatic,��i•o�n this claim or what you would like the City
to do to resolve this claim to your satisfaction. I(J��e `'t 4-
Vehicle Claims— lease com lete this se tion ❑ check box if this section does not a 1
Your Vehicle: Year Make Model �v�c
License Plate Number State /1 _Color�,(�C1C
Registered Owner v�
Driver of Vehic 0.u�c��,� (,e�'QbL�
Area Damaged �vQ,�` ' ,, � o��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Datnaged
Injury Claims— please complete this section i L�lcheck box if this section does not applv
How weie you in�uied?
What part(s) of your body were injured?
Have you sought inedical treatinent? Yes No Planning to Seek Treahnent (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 page
B�•si;�rinr rhr's for»,,yocr a�•e slcding thut all infonnation you have provided is true and correct to the best of your krrox�/edge. Unsir�red
f��rnrs tivill �rot be processed Subnritting a fu/se daiin cair result i�:prosecution. �
Print the Name of the Person who Completed hi l�o : ��1A/� C�,� (,QJ�.�Pi�
Signature of Person Making the Claim:
1
Date form was completed �1 '�f�J f 2OIt.J. Rcvised April 2007
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. PO Box 4025 ST. PAUL IMPOUND NUlVIBER:
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St. Paul, MN 55104 .
651-247-9783 -
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Address Towed From: , Date of Tow: ' -
;" ._ ; ;. ; , TYPe of Tow: r .:>
; ZONE �
Year. License#: ���i��
Make: Model: Unusual Circumstances:
VIN# :a .. �,�__.
Vehicle Condition: _
, _ , _, -
Towing Company:
rF' �'
Driver: �' Officer's Signature(for above)
Channel 5 Arrived Impound
� Tow Charges: $
� Extra Charges: $
j Arrived Cleared Impound
Invoice Total: $
Saint Paul Police impound Lot, 830 Barge Channel � �ad, Vehicle Release Form
Make: 97 HONDA License#: 494EPN CN: 13267540 Invoice#: 23553
Date/Time Released: 12/18/2013 20:42 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CP.RD Admin Charge: $ 80.00
Released by: KAYLA Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
! will check the vehicle for damage or any other problems that
� may have occurred while this vehicie was in the custody c;f the �ervice Charge: $ 0.00
Saint Pau{ Police Department. I acknowledge I will repurt
damage and/or any other problems to the Impound Lot staff Tot�l Charges: $ 219.50
on this form prior to leaving the impound lot.
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Damage and/or other�roblem: �1 ��t:� �.`� �j, ` J ,C-�C�� `��(1�., �
���t`��t.,��,:`s ��'� jd���� �'� �-%G���-LC�'
.
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
' TO PROTECT Y�JR�fGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE_LOT
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� � Signature� ;� ' � �����`'� _ 5�2000
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