Ojeoa RECEl10EQ
MAR 0 i 20 i2
p�'C�TIC:I� t)I+' C�.,AYN1 k'UR11� �ta the City of S��i�i��'�'i���nnesota
,4ainnesoln Srnra$Inturr.�66.US slul�s t;aaR " ...CvCry persnn...t+nix clai,na domJges jrnm vny municipaliry.,.shal,cause ro b�p;•aaerr�eri t�rht.
oo,�erniag bncly o,�;he rrtlrrtictntrli,y�+i�laln!SO dcrys nflEr the al;egaG ioss or injury is cliscovered c1 notics statiRY lhe ttats,pinee,anct
, cr,r�rn�srrtr�ce;l,)Cr@O�;�7/7GjlI'E 0'mpiiR!OJGOAip$�iSOff077 b!'0/hEt rg/►C,frt�n�nnc�ed."
Please complete tl�is form in lts e�1ti�•aty by eltarlr ty�•ioS or prit�ting your ans�k'tr Yo each qutstion. if more spsce is
neecIed,,�ttacT�sdditi.o��sl shcets. Plesse note that y�u wttl noc be centacheA by telehLone to clariiy answei:s,so prnvide as
much 3nfnrmatian tis.neeeas�ry to cxplain yaur claim,an�]the amount of compens�tion beln�requested_ 1'ou will receive n
W'ritten sGltstowledg:ement ance your farm iS rec�ivcd. 'Cl�e proeess can talce��p to ton weelcs or longer depancti�g or�the
nuture ofyuur clai�a. �'his form m�tst be signed,und t�ntli pa�es completett. !f r>amethinE does not apRly,write`N;:.��.
s�r� com�r�E.�n rorz� ,�Nn ox��nac�nvr�',1�T5 TO: crT�• cL��x�,
]�5 t�S71'K���,4GG� �L�D,3�(1 CIT�r�ALIL, 5:��[N'�PALTL,�CN 551�2
Fir,tNa�Y�e_ t � � �U� _ Middle Initinl � LastNTme C�-�/-�
Comp�ny or$usin�ss Name�� � --- � — ��
Are'You an )nsurance Cornpany^ Yas/Ne (fYes,CfaimNtlmber?
Street Adcir�ss �l�� (�/�-�7'T, � q l/� '� � ,
City�J .�t�1 (� StAte i�`�I bf.� Zi s�� ��—
p Cadc
Dnytime Phone(�?s�,;Z��t�Q�Cell Fho��e 6�_)2�3..4$0� �yenin�'f'elephonc(_� -_�
Data c�fp,CCidentl I�,jUry or Date I�iscc�.-ere�j�� J �;,, ri�;,�, I ��sam/pm
Please st�►to,i�1 detai�,what occu�red(lzappened,,and Urhy you ace submitting a claim.T'lease indic�te�,�vhy nr ho�v yau
feel the t:ity o'FSaint Pt,ul or its e�nrlcyees are involva��nd/or responsible for yot;r damages.� � (�
�..r A� '7t�..��� �� C c��2;�t� � � T' � S 4 rJ
D 2� �.•-� �1 i� 1-1 i�1� , -A N Y� T� t..�9-S � �l W h1 G��
� r- �a-c.��c�n � �r,_, 1�
���C��' wt U `�'' ►�"i �-!o'.r�3/� f? J=C.4 T �� OfJc:.� .
� �2_V1/1!ECZ. 1'Y1 D�!�S ,� T�l-t�°'�I •'-3 C G /�✓L G '- Lr2 0 �..r�.. Tx/L°`
��rS � <s Si o � >:/P�-�S -�� �.:� �c: GA-c�r� 4 T � �S�
�� ,�� o o C� , �..� �.v o tir�•7- �j�f 6,N t11�r rl L '�i�1-- t S 1�o N�� 7�/ �
A-�'L t� 1 v��—�-
F'(ease ch��k the uo�.�es)that�r,�st closely repi�esent tht,reasa��for compteting chis f�rm:
❑My vehicic��as dima�ed in at�acc:dent ; :��vchicle was darnaged duri+.�g a tc,�v
❑ My vefiicie�vas d:�m�ged by a pothole or eondition �f the street G M;�vchicic���as.iama�ed by fl plow
❑ My�ve:hiele w�s v,�ron�fully to�ued,�nd/ar tielceted � ❑ I a��s i�jurr�on City pcoF�erLy
❑ Other type of pro,�e�ty d�unage—please specify
❑Other type af ir1j�ry-pleASe spccify �
In order to process arour claim you need to include copies of;all�nnlic�ble docurn�ents•
For the ctaYms ty�es]isted below,�iefse Ue sure to i»c'.ude the documents indicltec�or it will de12Y tl�e;handlir.g af
your cl�im. Ltiocumr:;nts WI._ L�,Nt�T t,e reh�rned and become the propci��of tF�e Cit�. You are�ncoura�ed to Iceep�,
copy fpr yot!rselF be.'ore submittit�g ynur.;lain�Forni,
�� Pcoperry�iamage claims to a vehiele:two es,timates for Clte repRi�s tq your vehicle ifthe darnage excee;ds
S�S00.00;ar�:he actaal bills an�l/or receipts for r,he rap�irs
(J Towir.g clnims: legible coF�ies af any ticket issued and a oopy ofthe imnonnd lot recEipt
;�Othar prc�percy dama��clt►ims:trlro repair�stimates ifti�e damage ex�etls�SO�,OQ;er tha actual bii;s
<<ndior receipts far t?�e repairs�,det�iled tist of clamag�i items
« tnji�ryclr�i�iZS: medicaf bift;�,;eceipts
eJ Photog�•ai�hs�re always we�lcome ta clacnnu,nt ancl su}�po�your cla ir;� buC���itl not be��et.n•ned.
rage 1 of 3-Please com�,lete s�ntl ret��rn both�ya�e�:of Claim Form
� � r'bJ�! �nei QCI.fi_G+;i_IGn ihlJlb: I i �in1 'Fi '�7�;
T+ailurc co complete a�sd ►Yturn bot4 pa�es�wilt resalt iu delay in�tlie hancllt�ag of yonr cla�Ym.
�All Cl�irr� - �ASe ..om 1 " section
�?;Were th:re witnasses to the inCident? Yes �� Unl.n�wn (ci►•cle)
; Provide tl�seir narnes,.addresses anci telE;phone numbers:
Vt�ere ti�e�olice or Ia•�xr enfarcement called? Ye:� 10 L'►�know�n (circlej
7f yes,what tlepa�tme��i:o�•agancy?` , C2se#er repcsiT#
Wliere dici che accide.:tit or ir:ju�y tf�ke Flflce? P�bvido strext aciditss,cross street,intersection,riame of,�arlc qr fr�cility,
closest IRndmark,eic, Pfe�se be As der�i!ed as possib?o. If ncCessary,att�ch a diag��am.
Please ifidicate�he arnount yo�i art,seekin�in con7ptns��tion ar tivh�t you �ueuld lik.e the Ciry to ao to rfssolve this el�irn
to yaur sa.tisf�ctior►.__T�-{� \/�p,l�V� C7� V✓� �1 C��. 1 5�' —�l�J�
�-S�L��GT- � � ��L _S -f� v'�vt� __.__-
i�icle(:l7ims-nt;:�se com�lete tDis s _'_ ❑ ch,:ck box if this sect'fln c�aes no:aonl_�r
'�our b�eF�icl�: Year "?c�C� Make �' ^— Model Vc�c_ s w���
LicensePlatc uulbert�?�16} 3 �Stateln� Calor_'�,Lou�
Register�d O�me� ���r,TZ,� ��� ��. �1�
DrivdrofVchicle '�r��- �� pT'���- ' `—
.4reF� D�mab�d�€�N$v�r s o � ��c��;,t R e� 171�1�-�r-'TI�L
CiTy V�2itiicie� "�'ear Make Mode)
Lice,.ise Plake N�unber $tace Coloi•
DriW�r�f Vehicie(City�mpl���ee's Nurne)
Area D�iiiageA
In4urv Claims-t�lease eum��ete thiF,seetion ❑eheck box i±this section does�ot an�iv
1-Iow werc you injtirc�d?
What pnrt(s)pf yottr bady were iryure�?
Have you sou�l3t medica!trc2tmcnt? Yes No Plamling to Sxk Treatn:2nt(ci��c:le) '
�h'he�t dici ycu recei��e�reatment?� (provide date(s))
Name of hledic�l P�•ovider(s):
Address_ .fielepF,o�ie
Did you�.niss w�rlc��s 1 resul;of yo«r injuxy? Yes ':�•Ic �
Whcn dic�you miss�,vork? _ �:prqviClB dsite(s)}
Name of your Emplayor:_ '
Address__ . � _Tolcph�ne
❑ Chec'k her��if yoa Are.�t�acl�9nb tnore puges to this clairn forn�. Nnmber of addltlonal pages
By signi ng tlris fn���rn,ynu nre sttrli�ag tJtnt a1!informntion��ou hai�e pro vide�l is trire aj�c�cor,►e�t to rlie hest
of ya�Pr knole�lerlge. U�signe�l f�r��ns��vill not be F�rocesser�
Srr6mirtiny r�,�`'nlse cla%tr� cart�°esrr�t in prosecutro,ri. Datefarn�was com�,leted �'J � � �_
Frint thr.N��ne of r.he Persan�vlyo t,'ornpleted this F'orm: I �
Signatiu•e qf l�ersoi:o Making tha CJf�im:
Revised 1':�brun:y 24l 1
7 �� Gxfi; �cr.i ��fi�,-A��%-� G; �h��;:t�: ! � ?i f17 '�7 'aa�
� m oun Lot, 830 �a�ge Ghanr�e� ��ad, V�hict� F�e����e � _
P
��r��
+.1/�a'ce: �4 VOLKSWAGON �icens2#: NYA383 :;4�: 12047044 a o _
,��»ic�, #: u 7i�8
��ate/Time Released: 03/02/2��2 00:22
1"ow Charge: � �23.�5 _
Fieleased to: TOTO . _-
Storage Charge: $ 15.0�
���d 'o�: CREDIT CARD
Ac�min Charge: $ gp,�p
�3eleased by: LARRY
Tax: (7.625%) � 15.55
I,ihe undersigned,have recovered the vehicle described ak��v�. Subtotal:
I will check the vehicle for damage or any other problems that � 234.50
rriay have occurred while this vehicle uvas in the custody of the Servic2 Charge: $ �.pp
Saint �'aul Police Department. I ac�Cnowledge I wiil report
d�rnage and/or any other problems to the Impound Lot stafif Total Charges: $ 234.5C
on this fiorm prior to leaving the im,�ound lot.
Damage and/or other problem: 't�;'p;? r�:�,, � ' r `� , r
� .� ��`� 1� � �'� f '� ✓' ^ '�'%��4 �T(�i
..._......,..�..�._.__._�. ..�.,�'2�'�..___....�Z_._..�.�..��.L -
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.�..��e.......��,.y..�.r._.._...,.......,.....�...........�.....�.:v�.�........�:..,.....r...�._..._...�...�... ._.._..�........��:�.
'�`+�"�"�ica Report made: Yes No
, ,
TO PROTECT YOUR RIG REPORT AIVY PROBLEMS/DAMAG�BEFORE LEAVIiVG T�i� �O�
� ���,�.,.._� _ _
Sic�nature --''
, " ' ,�
��.�,v.�` ,� _ : 5i2000
�,.''
- �
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 04 VOLKSWAGON License#: NYA383 CN: 12047044 Invoice#: 17158
Date/Time Released: 03/02/2012 00:22 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 15.00
Paid by: CREDIT CARD � Admin Charge: $ 80.00
Released by: LARRY Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50
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: $ 234.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made:Yes_No_ IF Yes, CN , If NO, Why?
QPRQTECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature 5/2000
St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 03/02/2012 00:22 Invoice #: 17158
Vehicle Plate: NYA383/MN
Payor: OWNER Location Paid: Impound Snow Lot ;
.
Citation: Amount:
888743813 $ 53.00
Total Amount Paid: $ 53.00
Paid by: CREDIT CARD
KEEP THIS COPY FOR YOUR RECORDS