Campbell RECEIVE� '''�
APR 012014 i
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NOTICE OF CLAIM FORM to the City of Saint P�itITlV1�11��
Minnesuru Srn�e S�uli��e 4(<i.05 s�cttes Ihnt "...everti�perscui...�vho cluim.c ticrrna,;es fronr any nuinrci�alit y....rhull causc in be presented ta the
guvernrn,G bndy n(the nnuricipality�riihin 180 dct��s ajter rhe aNeged loss or injia•p is discovered a notice stcding die tinie,pluce.«nd '
crrcunrstances!lrereo/:crnd the crmoim�u/contpe��sn�ion ur o�hc r relief de�nnnde�cL" ,
Please complete this form in its entirety by clearly typing or printing yo�r 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. The process can take up to ten weeks or longer depending on the
nature of your claim. This form mast 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
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First'�ame Middle Initial�Last Name����`'
Company or Business Name
Are You an Insurance Company? Yes/�do� If Yes, Claim Number?
Street Address r � � r` � _., i�
City c� ( �-� ` �� �
__State 1'L , Zip Code�_
Daytime Phone(���Cell Phone(�G�� %�
)�.�� Evening Telephone( ) _
Date of Accidend Injury or Date Discovered I
� Time__am/pm
Please state, in detail, what occurred(happened),and why you are submitting a claim. Please indicate why or how you
fee�he City of Sair.t P ul or its employees are involved and/or responsible for your damages.
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Pleale check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident �t1��
❑ My vehicle was dama�ed by a pothole or condition of the street �°'"My vehicle was damaged during a tow
❑ My vehicle was wrongfully towed and/or ticketed � MY vehicle was dama�ed by a plow
❑ Other type of property damage—p]ease specify � I�'as injured on City property
❑ Other type of injury—piease specify
In order to process your claim vou need to include copies of a�l app]�cahlp r����..,,o +
For the claims types listed below,please be sure to include the documents indicated or it will dela the han ' tr
your claim. Documents WILL NOT be retui-ned and become the property of the City. You are e coura;eddto keep a
copy for yourself before submittin�your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; oi-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 actua] bills
and/or receipts for the repairs; detailed ]ist 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—P�Qase complete and return both pages of Claim Form
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Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 05 CHRYSLER License#: 747VHJ CN: 14033708 Invoice#: 29356
Date/Time Released: 02/22/2014 14:08 Tow Charge: $ 123.95
Released to: TOTO �,j �'' ��� ' Storage Charge: $ 15.00
Paid by: CREDIT CARD ` ��� Admin Charge: $ 80.00
Released by: MOR �� Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50
I will 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 Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 234.50
on this form prior to leaving the impound lot.
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Damage and/or other problem:`t�'Z ��Y�� `�nn(�P.r t'�'
Police Report made:Yes_No_IF Yes, CN , �f NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
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