Boeshans, Adam REG�I�IED
JUL 212014
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�u��alf�LERK
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipaliry within 180 days after the aUeged loss or injury is discovered a notice stating the time,Place,and
circumstances thereof,and the amount of compensation 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,attac6 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 ,��m Middle Initial�Last Name �f Si-f�1J S
Company or Business Name M�l-}Z��(h MTIJI�J�C�1TS TTDT�I �£.S��C� /�}UGT's'D!�
Are You an Insurance Company? Yes/No ff Yes,Claim Number?���M� U�3
Street Address �C7C�� �f.�FF..��d� �-{t�'l
City��P�`L �I�G t�� State �1� Zip Code J���
Daytime Phone( �03)3�S-�Cell Phone( --j-----' Evening Telephone( •--►—
Date of Accident/Injury or Date Discovered (9�Z l � ( � Time am/pm
Please state,in detail, what occurred(happened),and why you aze submitting a claim.Please indicate whv or how you
feel the City of Saint Paul or its employees aze involved and/or responsible for your damages.�'f/�.'� ��'� Sf}141F o�
SiATt �'i4RfY1 T.I�JS (o �'CK4.fl ►ti� P� Zo��� CHC11Y S�i�)�R.4,�0 THA'T Wf�S f�Tlt£ �lnPt�N[)
Lo-r A+.�� ��;�5 �D�Z.r-�hrr� A -mr�t lcss U�P�o►� �rCt� �nP o�R Ct�tiLlL Fa� T�+� �HA�K(�f�S
oa� � i�-f43 Rc� � � ,�— au��. ui R�t�u�sT'
TN� o�1�e p�� �HA�2C-��5 '6� �s_.�'k�o�.fl i7�r� <)�c.µ �.a�rs P.nf2Efl uP oJ�1 3 7�i
Please check the box(es)that most closely represent the reason for completing this form:
❑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
❑ 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 vou 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 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 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 damaged items
O Injury claims: medical bills,receipts
O Photographs aze 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Ctaims—qlease comulete this section
Were there witnesses to the incident? Yes No Unknow (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,attach a diagram.
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.
Vehicle Claims—please complete this section ❑check box if this section does not applv
Your Vehicle: Year Z�Z Make CNc.t�Y' Model Sr�U��D� f��
License Plate Number State MA3 Color�-�l�'I
RegisteredOwner�f�ut l3�tNL� S'C'1�T� �4RM TNS(�iJC.�
Driver of Vehicle i4u t
Area Damaged 20��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
�iurv Claims—please complete this section Q'check box if this section does not anvlv
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 attaclung more pages to this claim form. Number of additional pages Z
By signing this forni,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �/ �7 l z� 1�
Print the Name of the Person who Complete is orm: D�rn 5����
Signature of Person Making the Claim: �� D��n����
��
Revised February 2011
Accounting Detail Page 1 of 1
:�, AdamBoeshans,Profile: TRACS:2.3820.20140615,Region:TRACS Enterprise
'TR,4 Minneapolis �.' �—���� ��„���
Accounting Buy Chgs-205 Assignment New!Edib9 Dispatch Reports-50 Stall Units-61 Checks,Adv&Sublet-239 Acwunting Pmt Rev-204 Assignor Maini-277
Accounting Enh-197 Assignment Sfatus-7 Dispatch Management-3 Yard Checkou68D Titie Processing(,0)-105 Assignor Pmts-220 Move Docs ior Stock-107
AccouMing login-57 Dispaich-Tnage-58 Phmos-Change Stock-65 UpCaie S�atic Info-235 Checks,Void Issued-225 Atljus�er Mgt-68 Checks,Buyer Refund368
Seller Paymenis-25 Sale Marking List So-2100
Dispatch Ma�o"34 Auctioneer List-2302
Yartl Inventory-2605 Sale Units Pending A-2304
E�x)it
Accounting Detail for StodclD:8895278
No Assignor Payments Recorded
Net Chedcs Issued
Chedc Date Chedc Artwunt Chedc Number Payee Cleared Bank
07-07-14 978.57 23679-11 State Farm Insurance-Heartland Zone 07-08-14
Advance Charge Chedcs
Chedc Date Chedc Artaunt Chedc Number Payee Cleared Bank
03-06-14 �285.68 36633-14 Impound Lot 0311-14
No Sublet Tow In Checks Recorded
No Sublet Tow Out Chedcs Recorcled
Other Chedcs
Check Date Check Amount Chedc Number Payee Cleared Bank
F�cpense Account Memo
0415-14 20.75 27937.00 DVS O4-30-14
5500 Title App for 8895278
Buyer Payments
Payment Date Payment Artaunt Reference Company PmtType-Depld
07-08-14 1,630.00 INTERNACIONAL AUTO SALES LLC CH-60508—�
http://tracs.coxinc.com/etracs/NApplications/AccountingDetail.aspx?StockID=8895278&e... 7/18/2014
Page 1 of 1
Stock# 569851 Lot# 8895278 Claim# 23-29M9-083
Sainf Pauf Polic� (mpound Lo�, $30�arge Channel Road, Vehicle Release Form
, ; ,
Make:42 CHEVROLET License#.356KKA CN: 14038158 lnvoice#:1493�1
Date(fime Releas�:0310112014 09:10 Tow Charge: $ 60,00
Releasetl ta;TRA Storage Charge: $ 120.OQ
Paid by,CHECK Admin Charge: $ 80.00
�
Released by:J PAUL Tax;(7,625°/a) $ 10.68 'I
!
�
I,�he undersigned,have recouered�e vehicle tlescnbed a�ov�, Subtotal; $ 27a,68 ;
I will ch�ck the vehicle for damage or any otl��r�oblems�at ;
may have occurretl while�his vehicle was in the cust�y of�e Service Charge, � 0.00 �
Saint Paul Police Depa�ment, l ack�owl�ge I will repo� �
damage andlor any other problems to�e f mpound lot staff Tatal Charges: $ 210.68 �
. �
on�his form p�or to leavmg the impound f ot.
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Damage andlor o�er problem: �
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Palic�Repor�made:Yes,�„Na,_IF Yes,CN_,_,!f N0,Why? I
I
, ;
TQ PROTECT YOIiR RfGHTS,REPORI'ANY PRQBLEMSIDAMAGE BEFORE LEAUINC THE lOT �
!
Signature ��
.
http://tracs.coxinc.com/etracs/NApplications/DisplayPics.aspx?stockid=8895278&exit=close 7/18/2014