Ransom, Lavenna R���y�`�I��
SEP �9 2�14 '
�1OTIC� ��' CLAIM �ORM to the City of Saint Paul�i'�i1�o�p�
Minnesota Stnte Stata�te 466.0�states thnt "...ever��persai...who claims dnmages_fi-om nriy�mu�ticipalin�...shall cnuse to be presented ro the
ooverni��,;body of tlle�nunicipalit��tivitllin 180 dnys afYer the n4leged loss or i�ijairy•is discovered a notice stating the time,place,mid
circatmstnnces rhereof,and the amoarnt of compensntion o+-other r-elief demartded."
Please complete this forin 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 explain your claim,and the amount of compensation being requested. You will receive a
written acl�nowledgement 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 sianed,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�A , Middle Initial�Last Name, �
Company or Business Name
Are You an Insurance Company? Yes/�o If Yes, Claim Number?
Street Address ��d C��G��1�'L.�� -
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City ����i,� State ��Y�'y� Zip Code;>�;�,�.�
Daytime Phone(� 7��_c��ell Phone��' � � ~ EveninQ Telephone��!��"'��
Date of Accidentl Injury or Date Discovered �`/tlf��d/G� Time am/pm
Please state,in detail,what occurred(happened), and why you are subinitting 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.
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Please check the box(es)that most closely represen the reason for completirf�this form:
My vehicle was dama�ed in an accident �v1y vehicle was damaQed during a tow
My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was dama�ed by a plow
�My vehicle was wrongfully towed and/or ticketed }was injured on City property
Other type of property damage—please specify �Gs2'� � �l�4� '�/�S
❑ 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 handiinD 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 submittin�your claim form.
•Property damage claims to a vehicle: two estimates for the repairs [o your vehicle if the damaQe 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 damaQe exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
• PhotoQraphs are always welcome to doc�ument and support your claim but will not be returned.
Pa�e 1 of 2—Please comp7ete and return both pa�es of Claim Forni
�ailure to camplete aa�d return both�ages will result in delay in the handling of your claim.
All Claims-nlease complete this section
Were there witnesses to the incident? � No nkno (circle)
Provide their names, addresses and telephone numbers:__.����P.iL �-t�S2_ ����z�- ���
Were the police or law enforcement called? es No Unknown (circle)
If yes,what department or agency? S.!t� Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,n me of park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. ���i�'7��._ �
Please indicate the amount you are seeking in compensation or what you would like the�y to do to resolve this clai
to your satisfaction. �� f�� /h�� � Q � �
�/?1'c'_� ��G�t.l���c�� ��i'-�S .� i�`�"la� -� �b�,
Vehicle laims- lease com lete this section check box if this section does not a 1 ,�r'���
Your Vehicle: Year,�L Make Model GG�--1za��
License Plate Number / - _Stat Color
Registered Owner^� .!�^i-i �'ah
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area DamaDed
Iniurv Claims-please complete this section �Skeck box if this section does not apply
How were you injured? �CS
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
�heck here if you are attaching more pages to this claim form. Number of additional pa�es�
By signi�zg tliis form,you are statin�tlzttt all infornzation yoac Iiuve provided is true and correct to tlze best
of your k�xotivledae. Unsig�a,ed forms will not be processed.
Sub�nitting a false clai�n c�a�i result ira prosecutio�a. Date form was completed -;��- /
Print the Name of the Person who Completed this Form: ,
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Signature of Person Niaking the Claim:
Revised February 2011
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Sain� Paui Police Impound Lot, 830 Barge Ch�nnel Roac9, Vehicl� Release �-orm
Make: 01 CHEVROLET Licsnse#: 164KEK CN: 14168749 lnvoice#: 152053
Date/Time Released: 08/19/2G14 20:38 Tow Charge: $ 60.00
Rzleased to: TOTO Storage Charge: $ 120.00
Paid by: CASH Admin Charge: $ 80.00
Released by: BECKY Tax: (7.625%) $ 10.68
I,the undersigned,haue recovered the vehicle described above. Subtotal: $ 270.68� �
I will cfieck the vehicle for damage or any other problems that
may have accurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Pauf Police Department. I acknowledge I will report
damage and/or any other problems to the impound Lot staff Total Charges: $ 270.68
on this form prior to leaving the impound lot.
��;; Damage and/or other problem: � ,�,���� �i"w=�.7 •'��� �C=��-�"�-� �'� �-��i-�=J
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Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PRQT CE T YOUR E�IGHTS REPORT ANY-P OBLEMS/DAMAGE BEFORE LEAVING THE LOT
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