Sanchez, Jose NOTIC� OF CLAIM I�'ORM to the City of Saint Paul, Minnesota
Minitesota St�ite Stc�h�te 466.05 stntes that "...everv person...who clninis danrnges,�rnnt nnv ntunicipnlity...sht�!l cnt�.se to be p�-ese�tlerl tu the
go��ernir�g borly of dze municipn/i/y H�i�hin I80 dcn�s after t/ie u//eged/oss or injurv is ctiscuvered a i�otice stuting[/ie time,p/nce,nnr/
ci�-c�unstuirces tJ�ereof,nnd the amount of compensntion or other relicf denrnnded."
I'lease complete this form in its entirety by clearly typing or printinb your answer to each question. If more space is
needed,attach additional sheets. Please note th��t you will not be contacted by telephone to clarify�nswers,so provide as
much information as necessary to explain your claim,and the amount of compensation beinb requested. You will receive�
written acknowledgement once your f'orm 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 bolh pages 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
✓ -
First Name ,s1�5� Middle Initial�Last Name --S�nv �Z r`'r'^'—�VED
Company or Business Name
N 1201�t
Are You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address ���� ��� s� � , CITY CLERK
City Si /��v/ State i�7� Zip Code ,s S ��y
Daytime Phone (�)�- �C�` Cell Phone ( ) - Evening Telephone ( ) -
Date of Accident/lnjury or Date Discovered �/� -/�-I� Time .� � �i`/ am/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 y�o�r damages.
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Please 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 durinb a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
�,My vehicle was wrongfully 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 applicable 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 comptete 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-nlease complete this section
Were there witnesses to the incident? Yes � Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No� 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.
Please indicate the amount you are seel:ing in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims- lease com lete this section check box if this section does not a 1
Your Vehicle: Year�� Make � Model
License Plate Number X�G°� S Z State��i�i, Color �'���
Registered Owner �Sr° />� ����C' -Z _
Driver of Vehicle .�nSe � _,�r����' Z
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniury Claims-please complete this section ❑ check box if this section does not apply
How were you injured?
What part(s)oY 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
Pd�Check here if you are attaching more pages to this claim form. Number of additional pages -Z
By sigrting tltis form,yorc are stating tltat ull information you jtave provided is true and correct to the best
of yoc�r knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date f'orm was completed �� "����/
Print the Name of the Person who Completed this Form: ? ' - � n ��Z
Signature of'Person Making the Claim:
Revised Febru�u-y 201 I
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
� Make: VOLKSW�GEN License#:XLC852 CN: 13267540 Invoice#: 23422
�
� Date/Time Released: 12/18/2013 11:53 Tow Charge: $ 123.95
� �\ Released to: TOT(� Storage Charge: $ 0.00
� � Paid by: CREDIT CARD Admin Charge: $ 80.00
� ♦�
� � Released by: BONNIE Tax: (7.625%) $ 15.55 ��
� �
\ �`'�
`, I,the undersigned,have recovered the vehicle described above. Subtotal: $ 259.50
�, n+ !w���!! �h��k fhe vet`:':,I�fcr darnage or any othet�probie;ns ihat _ .
� �p� may have occurred while this vehicle was in the custody of the Service Charge: $ OAO
Saint Paul Police Uepartment. I acknowledge I will report
h damage and/or any other problems to the Impound Lat staff Total Charges: $ 219.50
� � on this form prior to leaving the impound lot.
` ��
� �amage and/or other problem:
�
�
Police Report macie: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS. REPORT ANY PR06LEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000