Yann, Bee RE�EIVED
MAR 112014
Y
CITY CLER�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Mirrues��ln Sla�e S�crlutc 461i.U5 suues r/TCU "...ei�er����e�sun...�cho clairns dumnges from cmy'mc�nictpalih�...shatl cut�.se tv be presenred�n Nie
��!i�errlin;find}•�f N�e nnu�icipaliR'witt7in 1$0 dcr}s ufter the ctlleged.1oss o�'i!tjzti��is discot�erecl a nvrrce staring dte rime,l�face.anct
t•rrcumslunces!lrerecf;u»r!tl�e amo�uv u�cnny�ensation nr otlrhr rrlrejdemm�clect."
Please complete this Form in its entirety by clearly typing or printing vour answer to eaeh question. If more space is
needed,attach additionai sheets. Please note that you will not be contacted by teiephone io clarify answers,su pruvide as
much information as necessary-to explain your claim,and the amount of compensation being requested. You wi[t recei�e a
�vritten acl:nowledgement once your forn�is received. The process can take up to ten weeks nr longer depending on the
nature of rour claim. This form must be signed,and both pages compieted. If something does not apply,write `N/A'.
SEND COMPLETED FORM AND OTHER D4CUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First'�ame $c?,� Middle lnitial L' t,ast Name Lrat��t�(
Company or Business Name
Are You an Insurance Cor�zpany? Yes!No If Yes,Ctaim Number?
Street Address�_ ��,r;�5 .�,,�,,�.�- ��,, � �g
r
City_lc�-Euar �-�y ;rt State M�/
Zip Code�
Da}�time Phone � ��'�
t—�-)�.-�C�t Cell Phone(�}��Evening Telephone( )
Date of Accidend Injury or Date Qiscovered p
—�-� .—Time �� �y pm
Please state,in detaii, what accuned(happened).and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are invoived and/or responsibte for your damages.� �
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Please check the box(es)that most etosely represent the reason for eompleting this form:
� VIy vehicle was damaged in an accident
❑ M}� vehicle was damaQed b a �My vehicle w�,s� oa.�,ed��$�. _ ___ __
❑�v Iy v e h i c l e w a s w r o n g fu l ly to w e dt anct/or tic�ketedn of the streer L T 1 C�[y v e h i c l e w a s d amage d by a plow '
C� Other type of property damage—p]ease specify � I�'�injured on City propetty
❑ Other type af injury—please specify
In order to process your cIaim you need to inclade coaies o#'att aonlicabte d eja� ts
For[he cIaims types]isred below,piease be sure to include the documents indicated or it wiIl delay the handling of
your claim. Documents WI_ j,L r(p'r be returned and become the property of the City. You are encouraged to keep a
copy for yourseif before submitting your claim form,
0 Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$S�0•00; or the actual biIls and/or receipts for the repairs
R O Towing claims: legibte copies of any ticket issued and a copy of the impound Iot receipt
O at�ier plvperty dama¢e claims: two repair estimates if the damage exceeds$S�.pQ; or the actual bills
and/or receipts for the repairs;detaiied list of damaged items
O Injury ciaims: medical bil)s,receipts
O Photographs aze always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and reiurn both pages of Claim Form
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Saint Paul Police impound Lot, 830 Barge Channei Road, Vehicle Re(ease Form
Make: 96 HONDA License#: 920JHR CN: 14040882 Invoice#: 29544
Date/Time Released:03/08/2014 12:05 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: RITA Tax: (7.625%) $ 15.55
i,the undersigned,have recovered the vehicle described above. Subtotai: $ 219•50
I wili 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 Paui Police Department. i acknowledge 1 wiii report
dam�ge ar��r arry ather probiems to the ttr►pottnd�ot staff Tc>tal Charges: $ 215.50_ _
on this form prior to leaving the impound lot.
Damage and/or other problem: froc^,`t" ��+��. Cu��- ��
Police Report made:Yes,_No�IF Yes, CN , tf NO,Why? C�—�rs� ��w �1'`�^ �'� �"'f�
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature s�2000
i.
St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 03/08/201412:05 Invoice#: 29544
Vehicle Plate: 920JHR/MN
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900231321 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CREDIT CARD
KEEP THIS COPY FOR YOUR RECORDS