Campbell, Brent ._ _ ��c�n���
�iJN 2 6 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne ota
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Minnesota State Stntute 466A5 stn/es tha[ "...every person...who clainu dnmuges from nny municipaliry...shall cattse to be presented to lhe "��
gnverning body of ahe municipaliry wid2in 180 days after die alleged loss or injury is discovered a notice stating the time,place,ancl
circum.rtmxces thereof,and the amocuit of compensatian or other relief demanded."
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 expiain 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
First Name '�,nq,�,1' Middle Initial_�Last Name��,���
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address �°�'Z� 1�f'(ti �.1t 5
City (�•�vu�:?o���S State (�fJ Zip Code �5���
Daytime Phone( ) - Cell Phone(�2� 3.f5 0l Evening Telephone( ) -
Date of Accident/Injury or Date Discovered � 2�� Time � a /pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you I
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. �I
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Please check the box(es) that most closely represent th�reason for completi g this form:
❑ My vehicle was damaged in an accident �VIy 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
❑ My 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 applicable 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 b�come the property of the Ciry. 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 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 actual bills
and/or receipts for the repairs; detailed list of d&maged 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 p�ges of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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, attachn a diagram.
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Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
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1"�WC� �'O�C.y �,4Y� �.H.iJf:v'`✓�� �
Vehicle Claims— lease com lete this section ❑ check box if tf�is section does not a 1
Your Vehicle: Year ?s�� Make ijt..J Model �
License Plate Number Z�C:�k�S 1 State�t�Color ��tn,�e_
Registered Owner �r^ � �
Driver of Vehicle 1�ir�-�" ' �
Area Damaged � � �+M�r'
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 ;�heck box if this section does not applv
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 miss work? (provide date(s))
Name of your Employer:
, . - - - _-_---_ _--__ ____
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By sig�zing this form,you are stating that all information you have provided is true and correct to the best
of yoacr knowledge. Unsigned forms will not be processed.
Szib�nitting a false claim can reszclt in prosecution. Date form was completed `�� ��' ���
Print the Name of the Person who Completed this Form: j�f'�•w"�` ��,t�� ��
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Signature of Person Making the Claim: �°� " "" '"�
Revised February 2011
1 i
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 00 VOLKSWAGWN License#: 2CX751 CN: 14107928 Invoice#: 150890
Date/Time Released: 06/01/2014 11:00 Tow Charge: $ 60.00
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: ALLYSON Tax: (7.625%) $ 10.68
I,the undersigned,have recovered the vehicle described above. Subtotai: $ 150.68
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: $ 150.68
on this form prior to leaving the impound lot.
Damage and/or other problem: _�� ti -r � �Ji� t r=�.� '' ��-�'L� ��,�,i,`-'^,�'��
r ;
1,ivti..�� � � G�n.; •' !/�
Police Report made: Yes_ No�lF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
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Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 00 VOLKSWAGWN License#: 2CX751 CN: 14107928 Invoice#: 150890
Date/Time Released: 06/01/2014 11:OQ Tow Charge: $ 60.00
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: ALLYSON `�sT^Pp� Irypp�LOT Tax: (7.625%) $ 10.68
830 BARGE CHANNEL. RU
I,the undersigned,have rec SAINT P65,�_5�207_2q50 Subtotal: $ 150.68
I will check the vehicle for TermhTDt 0g173q�3�iq4
0000800638014q08
may have occurred while 1 Service Charge: $ 0.00
Saint Paul Police Departrr Sale
damage and/or any other XXXXX%XXX%%%5158 Total Charges: $ 150.68
on this form prior to leavir �j$� Entrv I�thod; Swiped i
Damage and/or other prc iotal: $ 1�0.68 'r �""��'r —
06�01i14 11:41�17
Inv�: 00�9q p��r Code; 111014
A�rud; Online
Police Report made: Ye� _, If NO, Why?
Customer L'oc,y
TO PROTECT YOUR R THANK YOU! /DAMAGE BEFORE LEAVING THE LOT
Signature � 5i2000
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