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Goodman
RECEIVED NOTICE OF CLAIM FORM to the City of Saint Paul, Minr��o�a 2��4 Mi�t�teso�a Stute Stun�te 466.05 states tha[ " ...every persnn...wAo clnims dmm�ges,(ram miv mtuticipnlity...shnll cnu.ceC I,TY,����K go��erning body of t/re nuinicipn/iN witl�in /80 du>>s nfter the a//eRed/os.r or injury is discovered a�totice stnting t/�e time,pince,u�id circtanster�tces tlrereof,and dre amo�mt of conrpen,rntion or other relief dentnnded.° Please complete this form in its entirety by clearly typinfi 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 1s 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 `�"��� C�ood�nc�n First Name_T4 I�i ,� Middle Initial�Last Name Company or Business Name Are You an Insurance Comp�iny? Ye. /No If Yes, Claim Number? Street Address �� a a Ma�rSh�.l� ��i- City ��' ��.�� State � ,v Zip Code ���� Daytime Phone ( ) - Cell Phone �5i >3�R_ 352�vening Telephone ( ) - Date of Accident/ Injury or Date Discovered �"I�D- I� Time� '��Am a /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 your damages. �o e�r Pr re �:t " a..rK- +� �1n e e o�.r- o�..y-e :-�.�.r (�a-✓t � '' � T2w.. �/�/e a� „� ; p'S—LF U r F.vPirG�,� w e� Ca i.w� vt�j �na- ; � ,n ov. o�...r - Lv.:�-iy�! , (.�I�o�-hoocT � �l i- •rei'N-;G(,'�,, . /1/ b f✓� � i� Oli W� � Q �C � V�dl'Y��1i if� VIq.V � r K� -�' t�CQ:V c�) i.�.v�.-v� o v-- Q..-�l GCe :M' ( C:.. G✓�. W�� �.6 � �'°PZF 1.e1.�. � �UI,xC K i.�Q�E d- `I'� , /`1.SCor.n�.n:C�- Pleas�check the box(e� that most closely represent the reason for compTeting this form: 'E` ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ` ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow "�b1y 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 apnlicable 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 damuge exceeds $SA0.00; or the actual bills and/or receipts for the repairs f�f 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�njury claims: medical bills, receipts �f Photographs are always welcome to document and suppoR your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form railure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: � � (�ZZ /�.�I��ue(,7 a,v�_ GS � - 3�� -��5� Were the police or law enforcement called? Yes N� 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. L�ZZ �a,.-�(,�,, Gf �.c�c°, ���"'SG�.�2� S� (?��e�h �'l.Gt.v�Sl�.�� r.�,�..c� �-h�-. a..�' , , ��- ��-� Please indicate the amount you are seelcing in compensation or what you would like the City to do to resolve this claim to your satis action. � C�.v�� i . r ' � T' � G . � re.C,e�v� � ' G.Do �y, o� � � ow� c e, ►-�e,�b�,�-� Vehicle Claims—please complete this section ❑ check box if this section does not a�plv Your Vehicle: Year �Z Make C�MC Model C". �.v°y License Plate Number �S�FZ(� State G� Color lZe� Registered Owner �"�e� C�oo��+-� DriverofVehicle Car �Nc,3 ,��i.•--� Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Injury Claims—please complete this section check box if this section does not a�plv How were you injured? What part(s)of 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): Adclress 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 a taching more pages to this claim form. Number of additional pages ����S� By signing this form,you are stating that all information yor� have provided is trice and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date f'orm was completed �/l°��f t}' • � � Print the Name of the Person who Completed is For . � i Signature of'Person Making the Claim: Revised February 201 I y o� o cn � �, ❑ ❑ ❑ o 0 0 0 ..,; o � � o s•�� ; o p o c� n z o a c� c� cn D � � � � ,,: � � o Q v r- � o �- �m T � (D � .' 2 Z Cn m m m -,.�-m � O C �.:'Jm l.�,���S� m � W � a � Z � � � � � ��rn p � �D � S � O O � Vi tn N N � m <� N � � O �: f� y < y � C � ,� NO N � � � v .. fD y n�i fn � � m � m m m _. r `� �' d ..�,O ci p `.° m 3 v, � � � � � z Z � ? SU �c m o a _?o � m .� �";° n �� � � N � � Q� -�. ' n� O c° . Z fD y f/j � »' o � . _. .. °�.. ' o � ° � o m � m °' (n ^ � 3 �/� � m �co � � 3 p� I .� o � . _,.o n + � w^, . r� o a � m �i/ � N m m L1 A D - ? ... � . O � C�O� �n f� fD 'C C) " .., � O '� � � � o a 7 m �^ v � � �G m � � r,, ❑ _ � a m ❑ _ O f�R � �n 0 n -�w r: d � � �o, - o . st - � ` N ° o _ G� r., S � ? m � � �;. � ➢ 'D N r , N � � _ � ' � � � PP ... � � � .,' � Q � X ;}� � o - y W n d � a n .�.C) C7 �w C7 ^� ...m u`D, � 2 w w n � CI wo � `� > > > _-,. ? `�'o `1 � �' o co� � � V � � C � � � Q. �� �t Q (� (L] (� (� � � O � � . a (D (D (D (D .. �'O � � � � CO c0� n � � i ( o i . '. � C t�/1 3 � � � O O � ,' � ,. ❑ C�� .,�.m j. � � � � 3 �`�G -'�o m co � � � �' - m � m "' ❑ '.'ti` � O m � '� � �o' -o' . . -� .., �n t"�� m Q � � O � � °' � > > ° � � v ° � '..�m m � � Q � � .� .',. � �� � .A..:. � � C ^w.� ❑ 0 o ° my � a �`° �� � � � c� �, -� �, � � � c � � ; � °:� � � � � � ^` N o� � o � v ;,� � � � � � Z � � `G s � m v o� - O 5',v v m z o m � � � '1 � ert ❑ C C C , C �� 9 O.O � ~~� � � � � � N '� � �S � N CD N (D O � _.'fl . �D � �'m i,.� •�- � m � M C1 pt fl' Q a n. �D. � �� ❑ °-� N � °- ° o � � � � > > 4 � • � o L Z - _ �: o � _ _ ,: � � � a = �� �� � � `� o c ❑ o � � � � �.� : "".'`° � ❑ � s o � ' a 3 ao � � L�❑v �❑ r., ln � T rn � `o � O ° � '-'O � _° o� c� � r � N � (� m C� � � v 3 v l� � d ��°, � � � '' arn W ' V� y � 3 3 � ° �- n o � d -� ° � � � �j O. ❑ .n ''�,� y � � °; � N (}1 i � p 3 "' � v, �d �. _ ° � � � 3 0.� o.❑ o❑ o❑ -� �� � < a o ❑ ❑ -� I � a v, m � O �� � � y �, cn o n v w u;w m w fl; w � ° �. c"' a'a o'a o�a o o- m ❑ °-' ~ 'D fD y m � m m fD a > > � � w o ❑ �';n �n Q' � o� p m ;' 00 � N C IV �� �.0 �� ��D o. � N �iy���, Z7 C7 � a � 3 �� �� �� �� � C°ii � 0 � � � � � � � m o� � w �SO£EZ0060Z9 ._—.�>>–. impound Lot, 830 Barge Channel Road, vehicle Re ease orm ST PAUL 1MPOUNU L01 2t30 BARGE CHANNEL RD � License#:4SOF218 CN: 14040882 Invoice#: 296 SAINT PAUL MN. 5510i-245G 651-266-5642 Merchant IG: 8d0638F7144 )3/18/2014 10:06 Tow Charge: $ 123.95 Terin ID: GO1i340��k7iS006380144k)5 5ale Storage Charge: $ 30.00 zzzzzzzzzzzzl5i i Admin Charge: $ 80.00 VISp Entrv Method. 5aiped '� Tot31: $ ��g.5� Tax: (7.625%) $ 15.55 03�18�19 10.�5:45 Inv b; �����1 Appr Code: $9qi�2 e recovered the vehicle described above. Subtotal: $ 249.50 pPPrvd: �nline :for damage or any other problems that hile this vehicle was in the custody of the Service Charge: $ 0.00 c�ScoR,�,-c�uy �artment. I acknowledge I will report rf�aNh vou� ther problems to the Impound Lot staff Total Charges: $ 249.50 „ �aving 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 5/2000 Signature � . �''�' ' � � `� `�',�,l� I't�`f �� qt� . } ;� g;� � �r1 � ��� � ��'� �' ' - � t'y.� � '�.,. � � �• � � _`��� �,. �.;�<,. # � � � �� � ~, `, �, � . � .. � �� � � f�.6:. . ; � •� ��4 � � �� � ` ,. . .` 1.+��! 41�' �*,�� 1 h ' • ��r ti��1�'3 �` ' .( � _ ,�+ ,, y,�;. iY .,a{F* �� , ` ��' �� 4 a . - � . `r :!�� ^ , - . �s• '` i' � '� a � � � + w .... � � : �� � � �� . t �� .� � �:� � , r� . 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'��.. .�`k��. �R0 GA� �� ,I.p��'� ts�r���j� � 4f,.. �, � �t��. � ^'> �.,`����.. < /c i ,�d.� R �,� �y *lr,�'� �� �"`-`�"�4� ,�, '� yr �.��� IR��: ��.'��'�`' ,�,x� , � � �^�`.�`, t.�j���'� ��� `i��� � �a�' '.a ' �t�.�A���� a*��''' ` � � � � , G..-�• �. �.y,� ,Y�� :� ,( ►�` "' 3 +. F ,y"��0�{�AT".� ''� ynl7 � '.3FS ay;,�. .�,� �. .1 sr� ''.v�.,. � .AI�' , � A�-j n �i �ll� s�y, �.F�' '_ '� ��� ��� '�� Y +°"y..r�"�. ' �-- ! �,f) �� -� `ti,i�t',� �;1�'�:sLefT�' ���Pt � i� �' ai ,i �`'�'r. �! �'C"`� �s;� . L� O r' .��Y. - - i'� r F Y'°Y .v' .�,5 y A c t ``5 i Zro !' +.� A't ��tea` •�• �49�,� r�,r��46 `� '�i��4 8e i` � $��F iJAf.s�������� �i!��,$ti . �1, • �..____ fr. t �'� �� �'§��'�,l:,�,34 �''�" �. .�fi� c� a���l,r M� \; 3t . .. . . . � 4}'`�°'� � R �� h w�f t G .. i�� � � ` -`�r a�a�R `'� , � ,�� �� ��`I�J i�����J i � �p�tt�y� ;u � �'�` . � � , � . � t ��!f � 'iam+�t,�. � � @� �,j, r ;' � ��`�. . . . . , .�� t� � `1��N�f�t���� � �r� . c �y ....,.. , � �. 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