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Bjork NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Mitwe.;`>ia State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the '�overning body of the municipa[iry within 180 days after the alleged 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,attach additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. 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 Q,. Middle Initial�Last Name (� C-- ' ° Company or Busines ame, if applicable Mea 1 4 �(1� Street Address t� � � City �`�� C�,(,�,� State� Zip Code �v�� Daytime Telephone (�� °f�� ,�>)��V M� Evening Telephone (�) q� 7�� lo�z� ��eg '`1�'� �vM Date of Accident/ Injury or Date Discovered � 3 Time i ( am�ircle) — Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its.employe s are involved and/or responsible. C�c.t— � � r� —�?c..�ec�. s-Pi��n-`' �C n o GeJc�S �m v ` c� �� (' P �� EE sS �°�` � f � � � t(` �V J4 � "J I�/ _ ` c ` - � � �_ �- � � ° Please check the box(es) that most closely represent the reason for completing this form: ❑ Vehicle was damaged in an accident O Vehicle was damaged during a tow ' ❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ❑ Vehicle was �a�rangiully tcwed an�/or ti�ketP� ❑ Injured on City property � Other type of property damage—please specify � Other type of injury—please specify �, �'Other type not listed—please specify ; In order to process your claim vou need to include copies of all applicable documents. This is a general ! guideline of what should be submitted with a claim form, but it is not all inclusive. You may be asked to � provide additional information depending on your claim. O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the actual bills and/or receipts for the repairs �Towing claims: legible copies of any tickets issued and copies of the impound lot receipts O Other property damage: repair estimates, detailed list of damaged items !� O Injury claims: medical bills, receipts O Photographs can be provided but will not be returned. Page 1 of 2 — Please complete and return both pages of Claim Form Failure to provide a completed claim form will result in delays in processing. Notice of Claim Form, City of Saint Paul, page two All �C'IEs�ms- please complete this section Wer�� there witnesses to the incident? Yes No� Unknown (circle) If yes, please provide their names, addresses and telephone numbers: i �c �� Were the police or law enforcement eaH�"? Yes No Unknown (circle) If yes, what department or agency? C' �� ' � — � Case#or report# �t� ��`��J 7�� c��.�..�{ Where did the accident or injury take place? Provit�treet address, cross street, intersection, name of park or facility, closest landmark, etc. Please be as detailed as possible. If helpful, attach a diagram. J �;5�� C�c�-��5 �}-�� >��_ �'� -�'t�-,�`(= �-� rn.� ��v se Please indicate the amount you are seeking in compensation from this claim or what you would like the City to do to resolve this claim to your satisfaction�� (.�`.�`Lc�� (�t(� � `�-��v� ' yzc.�-�<� �k � �i-.- C � . 'LG'�.� � �� A Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year�Make `---- Model Cc�i,S License Plate Number �,?��- gv'� State��Colar �-�-� q t-E'F'(\ Registered Owner �'�F- � `- Driver of Vehicle � L� ' �� > Area Damaged z;-n_k. City Vehicle: Year��Make � Model License Plate Number State Color "iS$� Driver of Vehicle (City mployee's Name) � Area Damaged Iniury Claims- please complete this section ❑ check box if this section does not apply How were you injured? JU'� What part(s) of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) LVhen did you receive treatrrient? (provide dat�(s}) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone ,�Check here if you are attaching more pages to this claim form. Number of addidonal pages 2` By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms wil! not be processed. Submitting a fa[se claim can result in prosecution. Print the Name of the Person who Completed this Form: ��''1� � � ��' -� �,,_, „ � Signature of Person Making the Claim: � 1-'�'`�- - � C��C_ C.-� C� r � �`�-- Revised April 2007 Date form was completed J � c�tat�o�# g$g 7 4 5 7 4 9 ST. PAUL The uEde s gned,Ebe�g du RAMo EY pI�STRsC e�oa hp eposes and says: �`��,�„�f�f� * 8 S 8 7 4 5 7 4 9 * ' Date oi Offense � � � � i �Time of Offense � � ' � � I �J'�' Plate Veh.License No.� � ` ' Yea►�State � Make �' Q�� Style ��r Color�,�i— tocalion of Oifense: �� J ��{ � VIOI.ATION: � SNOW EMERGEMCY Si. Paul �rdinance 161.03 FINE $53.�0 ! CN 12+d47D��' (Amourrt indudes mandatory stafe suroharge9'of$13.04) Citing '�y�� Officer � Citing � 04f+cer �� Number �� Dept. '� ClPosted Night Plow �Plow owed in(Windrow} pTagged Betore Plaw �Drave Off OFFICER'S NOTES � ❑NO PLATE VIN: C11a1ion san be paid at ihe Impound Lot.Pleaae read the back of the citallon tor paymeM instruclfons. I COMPLAI NT St. Pau� Police Department for m Ramsey District Cour� � RE�EI�'T Date/Time: 03/01/20i2 21:14 Invoice #: 17121 Vehicle Piate: 930BVT/MN Payor: OWNER Lacation Paid: 4mpound Snow Lot Citation: Amount: 888745749 $ 53.00 Totai Amount Paid: � 53.00 Paid by: CREDIT CARD KEEP THIS COPY F4ft YOUR RECORDS Saint Paui Police Impound Lot, 830 Barge Channef Road, Vehicle Release Form _�. Make: TOYOTA License#:330BVT CN: i 2047044 lnvoice#: 7 7121 Date(fime Released:03/01I2012 21:14 Tow Charge: $ 123.95 , Released to:T�TO Storage Charge: $ 0.00 Paid by: CREDIT GARD Admin Charge: $ 80.00 , ; Re{eased by: ELIZABETH Tax: (7.625%) $ 15.55 I,the undersigned,have recovered the vehicte described above. Subtatal: $ 219.50 : I will check the vehicle for damage or any other problems that may have occurred whfle this vehicle was in the custody of the Service Charge: � 0.00 Saint Paui Police Department. 1 acknowtecfge t witi repart damage andlor any ather problems to the lm�ound Lat s±aff Totaf Charges: � 2'l9.50 on this farm prior to leaving the impound lot. Damage ancUor other probiem: Police Report made: Yes_No_IF Yes, CN , if NO,Why? _ TO PROTECT YOUR RiGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE t.EAVING THE LOT Signature �0°°