Drumgoole Sain� Paul Police Impound �ot, 830 Barge Cnann�l Road, Vehicle Release Form
Make:03 CHRYSLER License#:080DJX CN: 14008439 Invoioe#:25367
Date/Time Released:01/15/201412:25 Tow Charge: $ 123.95
Released to:TOTO torage Charge: $ 0.00
Paid by: CASH Admin Charge: $ 80.00
Released by:AMANDA Ta�c: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
i wili check the vehicle for damage or any other probiems that
may have occur�ed while this vehide was in the custody of the I Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will repart
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 anci/or other problem: /�7 i�'s��t g �,�5 St!C-�2/�7
��J
',;,i �v�,
Police Report made:Yes No_IF Yes, CN , if NO,Why? �, �
TO PROTECT YOUR RIGHTS REPaRT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature �r;,,.� ��e �0°°
�
R�C�IVED
�'EB 12 2�14
, � NOTICE OF CLAIM FOR�VI to the City of Saint Paul, M�"eYo�LERK
i
Minnesotcr Srnte Stutute 4<>6.05 sta�es drat "...every per:son...who cluirns dnmuges from an}'munrcipctlity...sltull catt,re to 6e presentet!to the
governi»,�hnch�of the municiperliry within 180 du�'s nfter the u(leged loss or ittjury is discovered a notice stating dte time,p[ace,nnd
circionslances llrereof,n��r(the nmoimt o/'contpensatra�or other relief de���anded."
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 that 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 a
written acknowledgement once your form is received. T'he 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 AN OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 10 CITY HALL, SAINT PAUL, MN 55102
First Name Z��q�('�UV S Middle Initial�Last Name_�('U q �O�
Company or Business Name �
Are You an Insurance Company? Yes/� If Yes,Claim Nwnber?
Street Address ��1y 7j ��,I I Cf-' �u2
City �-i- �v} State
--�� Zip Code S� t oy
Daytime Phone( ) - Cell Phone(�Sf )�_05 b Evening Telephone( )
Date of Accident/Injury or Date Discovered 1`�I � 3�� �
—��--�--r� Time�_am/
Please;;ate,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how yoa
feel the City of Saint Paul or its employees are invo(ved and/or responsible for your damages.
� � G f" t •
, _,
, �-
c.v eq�-t- �v, � . e �
� ' o ,� �-
i �.
'2b ��' �
Please check the box(es)that most closely represent the reason for completing this form: C ���t
❑ My vehicle was damaged in an accident ��m��
d❑ My vehicle was damaged by a pothole or condition of the street � My vehicle was damaged during a tow
1VIy vehicle was wr�n�fiilly towed and/or ticketed � MY vehicle was damagPd by a plow --�
❑ Other type of property damage—please specify � I`�'�inJured on City property
❑ Other type of injury—please specify
In order to process your claim you nee� to include coaies of all app��eahle 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 a�d 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 andlor receipts for the repairs
C9'Towing claims: ]egible 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 bil]s,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-nlease complete this section
Were there witnesses to the incident? Yes 1� Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes N_ Unknown
If yes, what department or agency? (circle)
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 dia ran�.
— �t1'Cc e�"�t�,l"15 ��� �ak- ty ve ar� � t�Y' �Vel'1U2..
5rt ���1
Please►ndicate the amount you are seeking in compensation or what you would like the City to do to resolve ihis claim
to your satisfaction. � �� ��
�lt��,11 0.ka li�r �v �'ei�e;� -�,��-� ��
Vehicle Claims- lease com lete this section ,�,/
Your,Vehicle: Year�t�U`�M�e -� S ��heck box if this section does not a 1
�r' Mode l ow(� � c u v t�'t�'-{
License Plate Number�� - � � +L State�IJ Color �i j���
Registered Owner �c � '�¢�,,�, �
Driver of Vehicle .c�i{��� v �
Area Damaged
City Vehide: Year Make Model
License Plate Number____ State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this section ,_,/
How were you injured? ��heck box if this section does not a I �
What part(s)of your body were injured?__
Have you sought medical treatment? yeS N�
When did you receive treatment? Planning to Seek Treatment(circle)
Name of Medical Provider(s): (provide date(s))
Address
Did you miss work as a result of your injury? l,es Telephone
When did you miss work? No
'�'ame of your Employer: (provide date(s))
Address --- -
Telephone
�Check here if you are attaching more pages to this claim form. Number of addition
al pages .'L .
By signing this for�n,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 cluim can result in prosecution. Date form was completed_��/�/�
f�---_
Print the Name of the Person who Completed this Form: Z�,'(� ' `�
" �5 ooLQ�
Signature of Person Making the Claim: '�
Revised February 201 1