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Davis, Jeremy NOTICE OF CLAIM FORM to the City of Saint Paui, Minnesota Nliiii�esotn Stnte Statiite=�66.05 stntes thnt °...ever��per-so�l...tivho c(nims dn�iinges from ruiy rniuiicipnlit��...slinll caaise to be prese�tted to the ooi�er-ning body of the mw�icipnlin�witlzirz 180 dn��s��f7er the alleged loss or injur��is discovered a�iotice stnting the time,place, mirl � circinnsta�rzces thereof,ruicl tlze nmo�.��at of co��7pe�isatiori or other relief tlei�inrided." � Please complete this form in its entiretv by clearl3�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 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 appl��,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 �e Ce""'"/ Middle Initial � Last Name �r^ `^ 5 C�C^C I�/G D Company or Business Name Are You an Insurance Company? Yes/� If Yes, Claim Number? Street Address "1�� "~ >� • � �� ( �I � City � G� +� ^'� Q�'`t'` � State � �^ • Zip Code S5 ��°� Daytime Phone (�) �S�S Cell Phone (�- ) "� - � Evenina Telephone(' ) � - — Date of Accident/Injury or Date Discovered Time am/pm Ylease state, in detail, what occurred (happened), and why you are submittinQ a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible far your dama�es. _ e��o a«s+ a�� -`-,�,k ,,.., Ve�,;�� _ N�5 �.� Y�{`.•;"�� .— o2�a �-1 � _� ,k5 �'� weol aro St. �.1 ��+n�►�^�l d+.�.e. tn exPi��d �4tis . M Y t;.rder S�w�-��..c� 1 5 ��1c�� G�' cwr Ca.-. D�� be �'n�ecti ;f �tib5 G►�e b�/o�-�l °CO d 5 ��ed . M Cwr �- n5 kow�� k� o^� Les ��-. �,o d�s i n2d�. �' (�e c�l Co wt�i �-e. �t �t �0 S ee i^�-Fi t 5 Co,,.1 d 1�e w�.�'�e al �'o� �.� � l� � `��S CG.�,,,sac� �n-• �^ t reK u ,^ -�o��„ -{a�'� cn��d n-��y ��ec.�e. riSStir� c.�.l� o�cc «�1� lc.�Ee �e��y . °� �1�-i-�.e 1.�rl�de�l �,.�,..,a� Please check the box(es) that most closely represent the reason for completin�this form: d. R�«�pi. „��'o ❑ My vehi�le�vas damaged ir�an accident _ ❑ My vehicle was damaged during a tow ❑ My vehicle was dama�ed by a pothole or condition of the street ❑ My vehicle was daina�ed by a plow I�I My vehicle was wronafully towed andlor ticketed ❑ I was injured on City property ❑ Other type of property dama�e-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 handlinQ of your claim. Documents WILL NOT be returned and become the property of the City. You are encoura�ed to 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 damaQe exceeds $500.00; or the actual bills and/or receipts for the repairs O Towin� claims: le�ible copies of any ticket issued and a copy of the impound lot receipt O Other property damaQe claims: two repair estimates if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs; detailed list of dama�ed items O Injury claims: medical bills,receipts � O Photographs are always welcome to document and support your claim but will not be returned. Pa�e 1 of 2-Please complete �nd return both pages of Ctaim Form I IOZ��qa3 pastnag :uicei� aq�Dutx�y�uosaad�o aan�eunis S�� /-�aJ a� :��03 slq�Pa�aidtuo� oqm uosaad aq�,�o atue�aq��urad � � � 9 � 1 � 1 pa�aiduio� sen� ui.zo�a�EQ •uo�n�aso.rd ur�1nsa.r uv� urtvp� aspv�'n.�u�7ucqns •passa�o.rd aq�ou 11zM suc.co�'pau�zsu� •a�pajMOUa�.c�zo�'�'o �saq a�� o��a.r.ro�puv a�zd� si paptao.rd a�n� �zo�'uo�vu�.ro�'ui P1v�n��.°uz�v;s a.rn �zo�f�zu.co,�'szz��uivazs rCg '�san�d i�uo��ipp�,�o aaquin� •uiao,��ui�t� srq�o�saned a.�oui nuiq�E;;� aae no��t aaaq��aq��, auoqdaia,I, ssaippy ((s)az�p apt�oid) :Ia�ojdcug zno�C�o atu�N �xiom ssiui no� pTp uauM °I�I sa� �,�C.mfui mo,C 301lnsaz� s�xion� ssrui no�p1Q avoudajaZ ssaipp� ((s)a�Lp apznoid) :(s).�apinoid I��ipa�3o aui�N ��uauz��az� ania�as no�pTp ua� (ai�it�)�uauz��aiZ xaas o�auruu�id oN sa� ��uau.i��ai�i��ipaui�qanos no,�an�H �,paznfut asan��poq mo,��o (s)1�d a�uM ____ nluue au�saop uoi��as srq��i xoq��au�" . _ . uot � _ �,pa.znfui no� alam moH � _ __---- .� as siq�a�ai uio�aseai —suit�� an_uI paD�ui�Q�aiy (auz�N s�aa�oiduzg�u�) ai�?uaA 3o ianuQ soto� a��s iaquznN a��id asua�i� taP�Y�i a�L�i �a,L :ai�tuan �C�1� paD�uitiQ�a.r�,� ai�ruan�o ianuQ iaun�p pala�staa� 1OI°� a��S .zaqumN a��id asua�t� J��(`�' `'a IaP°Y�I �i S S! a�Y�i��.�a� :ai�ruan ino� I �aou saop uor��as stu��i xoq x�au�� uot��as siq�a�at uio�aseat —suztei� atarqaA ui�i� siq� anIosas o�op o��at� aq�a�i�pisom�no��un�io oia�suad o�u Du�aas az�no�C�unouz� e T�a��i�ut=as�a�� • • u� � .P . Id 'LIIL'So°L'Ip E LI�L'��L °�sessa�au�I •aiqissod s�palt��ap se aq as�ald '��a `Xi��Pu�t asasoi� `�C�?it��.zo xs�d�o a �u `uoil�as.za�ut `�aaias sso.z� `ssaipp��aaz�s apinoid �a��id a��,C�nfui io�uapr�� aua ptp aia� #aioda.z.�o#ase� ��uaoL so�uauiu�dap�eun� `sa�C�I (al�z1�) umouxun �j sa� LPatI�'��vauia�zo�ua nnLi so a�Tiod au�asaA, �,% :siaquinu auoqdaia�pu� sassaippL `saui�u iiau�apinoid (al�1i�) umou>iufl � sa� ��uapt�ut a�o� sassaulim aia aia u� m aot��as s�q; a�ai, uzo� aseai —suaTei� II�' •uFrr.��1no�C�o Au�tp�Lq a�; u��eiap ut;�t�sa.z ��t.1� sap�d��oq usn�a.z pue a;ajduzo� a�a.�nire� � i�aint Paul Police impound Lot. 830 Barge Channel Road, Vehicle Release Form Make: 97 NISSAN License#: 222AHR �N 14213203 Invoice# 153037 Date/Time Released: 10/08/2014 16:42 Tow Charge: $ 60.00 Reieasetl to TOTO Storage Charge $ 105.00 , Paid by �REDIT CARD Admm Charge � 80.00 Reieased by BECKY Tax: (7.625%i $ 10.68 I.the undersigned.have recovered the vehicle descnbed above Subtotal $ 255 68 I wili check the vehicle for damage or any other probiems that mav have occurred while this vehicle was in the cusrody of the Service Charge $ 0.00 ; Saint Paul Police Department i acknowledge I wilf report damage and/or any otner problems to the Impo�nd Lot staff Total Charges $ 255.68 on this fo�m pror to leavinq the�mpound lot � ' __ ____ _ _ _ _ Damage�ndlor other proaLeAt._ I I � � � Police Report made Yes_No_IF ves. CN , If NO. Why? r0 PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature s�z000 --- — - -�..�, . _,.. _. .� f""�' .,� : ;�-- . �` . � .: � "�� . :_. - A�NNESOTA 1'2EQ�S't�A'fii)N�ARD!CAB CAR� � CURRENTLY, )VS IS UMABLE TQ PR9EESS YOUR REMEYAL `--"-^ IF YOD USf AB INTERNET BILI PAY SERYICE. Pl�asa uxa-this fora ta ranow in R�rson, by s�fi or at �AlIVI rNU� ��• ...._..� www•�ndrivainfo• g• Bill psy ch�tks y1li ba (�"�'��'�"��i"+'��If��t1��'I�(+��'��i��`c��l��l� tho��Qu�s�it Cal1�b51-2T6t9528ion thaL issuad PIl�aSQ lar.. � � �{��yr{�p�r ttf; A#16 2fl 14 . „� � , ��- - 5. � . : � �� _ -,x*M:4=�. . . .. i.;: _ . ` „ �'� �Fi ..m��}�'t.. ,.. . �,�k' �'r �'..a ' �-. ti.....:--�,v-��..��._..�_�.. __-��.� ..av -�-�_-�.�.�Ta.,_.._- '�+..-,-- �� c : . �. .._'_.`__ Pi.a r... �. v�M io�a,e.. M►•b d " 222 AHR 97 NiSS JNBAROSTXVY150100 23� REt318TRATIGN kN1�BMllMt N�a Fin@ �` MM�w1�0� TcRN TITLE TAX C#fNTRIlUilON FLE ' FN Fa Tu py� H13504396 35.00 6•0� b.[)0 10.00 52•fl0 Nrw E�on: AUG 2�315 noTyc,�: 1 pny cl�tach Iow�r Porlio�it Yau sn r«+�win�bY m�il.: ' � O� �U Q iip N �0 i!) ��tO 1 N _0 � _;�- y �V Ly ^,o -�5 �C �� #_ 't ' V��I� � a�n� M �.. _ � �e .�1 � _y, �� ` � 59°a�� M � � �r z - -- r% v�� s X o _' _- �� o n= K� �, " � -� �:-" a"�i a� �� ---- 0.��'