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� N07'ICE OT CLAIIVI FOIZM to the City of Saint P�tul, Minnesota
A4rnitesoln Slale Slntute=/66.05 slntes l/inl " ...ene�y persnn...ii�ho claims dnnuiges fi•ont mip nuu�icipn/ilp...sl�n/!cnttse!o be presented to Ihe
' go>>erning bndy nf the munrcipnlih�ri�i�iriii 1 SO dnys nfier Ihe alleged(oss or injury is discovered a nolice stating the time,pince, cuTd
cu•cwn:stn��ces Ihereof, nnd tfie amou�71�/'conlpe�asntion or other relief demanded."
Please complete this form in its entirety by clearly typing or printing yoin•answer to each question. If more sp�ce is
needed,attach additional sheets. Please note that you will not be contacted by telephone to ci�rify answers,so provide�s
much information as necess�ry to explain your claim,and the amount of compensation being requested. You �vill receive a
written acicnowledgement once yo�n•form is received. The process can talce up to ten weelcs 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'.
S�ND COMPL�T�D FORM AND OTH�R DOCUN[�NTS TO: CITY CL�RK,
15 W�ST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL,IVIN 55102
First Name ��1., Middle Initial (� L�st Name �'���„Lt
Comp�ny or Business Name
Are You an Insw-ance Com��any? Yes/'�' lf Yes, Claim Number? �' �'�(7`� l- 4-
Street Address �b,j`J �-f�-� �C / -.�}'1��Iv�.L�
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City � t �r�"�Ln Gt�.�%t�� State /V��N/�J�5��l� Zip Code��6
�
Daytime Phone (b;7�� L� Cell Phone( ) - Cvening Telephone(�O l.l�(-_`761�
Date of Accident/ Injuiy or Date Discovered � ' f1,tj��..1�j( �, Time � • l.�,J fllll�p111
- ., ---�—
Please state, in detail, what occurred (happened), and why you are submitting 1 claim. Please inclicate why or how you
feel the,Clty Of S1117t P ul or its employees are i►ZVOlved and/or res�on ibl for youc a'ma�es. /V� �'!�r i..;�'�3
t�J c✓- �a-� c'�t.t,�
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Please checl:the box(es)that most closely represe»t the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle w�s damaged during a tow
❑ My vehicle was damagecl by a pothole or condition of the street ❑ My vehicle w�s damaged by a plow
❑ My vehicle was wrongfiilly towed and/or ticketed ❑ I was injured on City property � .�
F�,Other type of property damage-please speciFy(yty �„�, �:,r�� S�'�"� �U� I����l���(�f,Ly1c�,� t.�11.
❑ Other type of injury-please speciFy
In order to process your claim you need to include conies of�11 annlic�ble 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 encou►�aged to l:eep a
copy for yow-self before submitting your claim form.
O Property damage claims to a vehicle: two estim�tes for the repairs to your vehicle if the damage exceeds
$500.00; oc the actual bills and/or receipts for the replirs
O Towing claims: legible copies of any ticl:et 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: medicll bills, receipts
O Photographs are al�v�ys welcome to document and support your claim but will not be returned.
P��;e 1 of 2-Please co�nplete�nd retarn both pages of Claim Form
. F�ilare to con�plete.u�d ret�u•n both p�ges���ill result in delay in tl�e handling of your claim.
All ClRims—ple�se complete this section
Wece there witnesses to the incident? Ye No Unl:nown (circle)
Provide their names, addresses and telephone numbers: F�l S 1�f�t�C,�1
t,( �' � o v� M�.1 ��
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? S a�-�,L Case# or repoct# C;N � 2.��2��3y
Where did the accident or injury tal:e place? Provide street address, cross street, intecsection, name of parl:or facility,
closest I�ndmarl<, etc. Please be as detailed as possible. If necessary, att�cll a diagram. r' j �
� f � P � C = �u� ti L.s�— v �' A-N � �T P,�.
Please indic�te the amount you are seel:ing in compensation or what you would like Ihe City to do to resolve this claim
to your sat�sfaction.��� • i9 7 • ��t,(1 CH�73-S� ��G�ir�j_�—1 l/�'('=Ef��/� •
Vehicle Claims—please complete this section ❑ checl:box if this section does not au�ly
Your Vehicle: Year fj�_ Mal:e j�/U' ,�} Model CL z
License Plate N��mt�er��� �(� State Color �/
Registered Owner _�,t���,c,t
Dciver of Vehicle
Area Damaged �f��`1� � �'��-L,��S
City Vehicle: Year Mal:e Model
License Pl�te Number State Color
Driver of Vehicle (City Tmployee's Name)
Area D�maged
L�jury Claims—lile�se complete tl�is section ❑ checl:box if this section does not au�lv
Ho�v were you injured? Al/l�-
� •�
What part(s)of your body were injured? ��/
Have you sought medical treatment? Yes � Planning to Seek Treatment(circle)
When did you receive treatment? (�rovide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss worl:as � result of your injury? Yes No
When did you miss worl:? � (provide date(s))
Name of your Employer:
Address ; Telephone
❑ Checic here if you are �ttaching more p�ges to this claim form. Nnmber of�dditional pages
By signing tltis fnrm,yon rrre sttding thnt a!l information yor� hm�e pronided is trrre�rnd cnrrect to the best
of yonr hiro�vle�/ge. Unsigired forms �nrl/not be processed.
Siibmitting n false clnini can resrrh in prosecutio�t. D�te form w�s completed �I�I�'Z
Print the Name of the Person�vho Completed this Form: r�iG L �'�( �l•(
.
Signature of Persou Malcing the Claim: �
Revised February?O1 I
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 96 HONDA License#: SGV311 CN: 12022535 invoice #: 136504
Date/Time Released: 03/05/2012 15:18 Tow Charge: $ 54.50
Released to: OWNER Storage Charge: $ 105.00
Paid by: CASH Admin Charge: $ 80.00
Released by: PERLITA Tax: (7.625%) $ 10.26
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 249.76
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 andlor any other problems to the Impound Lot staff Total Charges: $ 249.76
on this form prior to leaving the impound lot.
�, 1� f ,,t, �� t. ,, �;��- �±E�� ., � ,,, � 't__,� '��_�. , 4.�
� Damage and/or other problem: ��`�'�s +�,�,,�-�� l� ��, � � S � � ��%� � � � 1 ������ -
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Police Report made:Yes�No_IF Yes, CN I,��•C '1„�,'�►��`? If N0, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
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Signature %-��� � �-r""�� si2000
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Walmart . •..
SavQ money. Live bettar. j
( 651 ) 644 - 0020
HANA6ER AMY HAYDEN
1450 UNIVERSITY AVE W
SAINT PAUL MN 55104
STM 5431 OPf 00003146 TEM 06 TR# 06707
PRODUCT SEAIAL K JCA11034�50048
MA1(X-241 0681131�4216 79•97 X
BRTT CORE FE 0681�SUBTOTAL 89�97 0
TA1f 1 7.62TOTAL 96.07
CASN TEND 100.00
CHANfiE DUE 3.93
� ITEI�S SOLD 2
TCw 2416 53�Y 3431 9273 �6�8
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lou vrices. Euery dar. On euerythins.
Becked br our Ad Metch Buerentee.
03/06/11 13:36:50
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