Duncan RECEIVED
-- - APR 012Q14
NUTICE OF CLAIM FORM to the Cfty of Saint Paul, l��u�u�s�ERK
Minnesota Sfate Statute 466.OS states deat"...every person...who claims damages from any mwacipaliry...shall cause to be pr�eserued to the
governing body of the municipaliry within 180 days c{fter the a�leged loss or ir�ury is discovered a notice stating the time,place,and
circumstances the�of>and the amowet of compens�uion or other relief demonded"
r dnti our answer to each uestion. If more ace is ,
Please complete this form in its entirety by clearly typing o P ng Y Q �P
needed,attach additional sheets. Please note t�at you will not be contacted by telephone to dar�answers,so provide as ,
rauch information as necessary to eaplain your daim,and the amount of compensation being requested. You wiU receive a �
written acknowledgement once your form is receivecl. T6e prax�.s can take up to ten weeks or longer depending on the j
nature of your claim. This form must be signed,and both pages oampleted. It something does not aPP�Y�write�N/A'. '
SEND C4MPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST I�ELLOGG BLVD, 310 CITY HALL,SAINT PAUL,MN 55102 j
First Name ��{� ..__ Middle Inidal �Last Name �J�.�C��
_��
Company or Business Name
Are You an Insurance Company? Yes/ o Yes,Claim Number?
Street t�ddress �3 � � Q r � �
S�� �✓"G� '
City State � Zip Code� �
Daytime Phone(6�21�Zy �%Z Cell Phone(,� ) - Evening Telephone b��yL y yi y L
Date of Accidentl Injury or Date Discovered Time 7�U��1 pm
Please state,in detail,what occurred(happened),and why you are submitting a clai.m.Please intiicate hy��w you
fee the City of Saint Paul or its employees are involved aud/or responsible for your damages.�.
...✓���t �u,�- tu�„ �c,,�� - c�� r�te 6�.�� �,.�,� � eck�����.� .� ' ov .- ,
f u�er o w a i' ; v< � �:�. i i�/.�. /r� �v./ Uc.✓y'J�'t�'11
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r �/ Gv�' 3 h I/ . NU� I'P C i� / �/ . � �"G�A'•
Please check the box(es)that most closeiy represent the reason for completing this form:
❑My vehicle was da.maged in an accident ❑My vehicle was damaged during a tow
�My vehicle was damaged by s pothole or cc�dition of the su�eet ❑My vehicle was damaged by a plow
My vehicle was wrongfully towed and/or ticketed C]I was injtu�ed on City propeity
❑Other type of ProPertY damaSe—Please sp�ify
❑Other type of injury—please specify
In order to process yaur claim yo�need to include conies of all ann cabie dgcaments.
For the claims types listed below,please be sure to inclnde the documents indicated or it will delay the handling of
your claim Docun�ents WII..L NOT be retarned 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 velricle if the damage exceeds
$500.00;or the actual bills atid/or receipts for t�e repaus
O Towing claims: legible copies of any ticket issued and a copy of the im�aund lat receipt
p pther property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for t�e regairs;detailed list of dam$ged 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 complete and return both pages of Claim Form
_.- - ,
in la in the handIin of our claim.
Failure to complete and return both pa�s wiU res�ilt de y g y
All Claims-ntease comnlete this section
Were there witnesses to the incident? Yes N�C Unt�own (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enrforcement called? Yes 'N Unlcnown (circle)
ff yes,what department or agency? Case#or report#
Where did the accident or injury take plac�? Provide street address,cross street,intersection,name of park or f�cility,
closest landmark,etc. Please be as detailed as possible. ff necessary,attach a diagram.
Please indicate the amo nt you are seeki ' compensatio or what you would like the City to d to reso e this c '
to your satisfaction. ' ' ' • ' �^ � �< <
� a w✓ �_ � cf• S�' , - _ C((f P ' _ _
� �-�'t Cvc.t.✓�- r/v� /y �5� -
Vehicle Claitn�s-olease complete this section check box if this secrion does not avnlv
Your Vehicle: Yeaz Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Velucle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
1 � chec x' n
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):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you mdss work? (provide date(s))
Name of your Employer.
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of add�tional pages
By signing this form,you are stating that all information you have provided is true and correet to the best
of your knowledge. Unsigned forms w�ll not be proeessec�
Submitting a false claim can result in prosecution. Date form was completed -3�v��/
Print the Name of the Persson who Completed this orm:
' � r � ..C� c.�� c�
SignaU�re of Person Making the Claim:
Revised February 2011
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I
I
'�-----_. -.,,,` �
,Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicl� Release Form
�,,.�..,--�
Make: 01 SATURN License#�: XLR135 j CN: 14011327 Invoice#:26009
�
Date/Time Released: 01/19/'2Q14 11:03 harge: $ 123.95 �
Released to:TOTO Storage Charge: $ 15.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: RITA Tax: (7.625°/a) $ 15.55
I,the undersigned,have recovered the vehicle described abdve. Subtotal: $ 234.50
I will check the vehicle for dUmage or any other pro5lems that
may have occurred while this vehicle rvas in the custody of the Service Char�e: $ 0.00
Saint Paul Police Departmer�t. I acknowledge I will report
damage and/or any other prc�blems to the Impound Lot�taff Total Charges: $ 234.50
on this form prior to leaving the impound lot.
Damage and/or ather problem:�.(�l�
— -- . �� c:Cfi' .� ������
Police Report made:Yes_No V IF Yes, CN , If NO, Why? �P � i�!��'�'�''����7�i/�� �
�'Q��C���
T PR T T Y R RI hiT R P RT ANY PR BLF_M�/nAMAGE BEFORE LEAVING TH LOT /� l�-
Signature � --- � ; G������ " �`2300�
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