Kasper NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Mr�inesoi�State Stnt�ete 466.05 states tliat "...ei�ery person...wl2o clainzs damages fi�om any�nieriicipality...s/iall ca�ise to be presented to the
gorerning bod��of the mmiicipalily wrthin 180 dars after the alleged loss or irijiin•is discorered a rloliee stating the time,place,and
enrumstances thereof,and the amount of co�npe�asatiorz or other relief dernanded.°
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 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 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 E Last Name ��A S pE�TL_
C�mnany or Buciness Name___^'/�`__—.—_._-- _ __RE�►E�VE�
Are You an Insurance Company? Yes/No If Yes,Claim Number? N liD. t�!'�il � � ���
Street Address 1023 WltNU� l-kaLl�. Pn�E. � �'h/��G1C
City �T l��t� State /�N Zip Code 55 l O
Daytime Phone (9��1 )�-�Cell Phone(g� )'o -�Evening Telephone �9 ) 0�8 - 3945
Date of Accident/Injury or Date Discovered o1 �R.CN 20t2 Time �g�� am pm
Please state,in detail,what occurred(happened),and why you are submittinb 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 represent the reason for complering this form:
❑ My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
❑ 1�Iy vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
C�My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property
❑ Other type of property daniage—please s�ecify_
❑ Other type of injury—please specify _
In order to process your claim you need to include coqies of all apnlicable 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 encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
C�?'�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 damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:N�/k
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? tJ�D� Case#o N
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or faciliry,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram._T
Please indicate the amount you are seeking in comp nsation or what you would like the City to do to resolve this claim
to your satisfaction. 2�72 50 -�-��. �� o o -}iUG.G��-219 00 ini.�U��
Vehicle Claims—please comnlete this section �check box if this section does not a�plv
Your Vehicle: Year O��_Make �oy u�12. Model_�,�
License Plate Number 5Dre 304� State LJ�Color l�iw�
Registered Owner ��� IGs.S�p�2_
Driver of Vehicle N/A
Area Damaged__N/A
Ciry Vehicle: Year N/,,�Make N�A Model �Jf1l
License Plate Number �.,t�4 State�[p,�Color N�A
Driver of Vehicle(City Employee's Name)�•1��
Area Damaged ►�la.
Iniurv Claims—please complete this section check box if this section does not applv
How were you injured?
What part(s)of your body were injured? ,
,i
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 Telephcne
C�Check here if you are attaching more pages to this claim form. Number of additional pages Z . `
� �'tc.� '{ l�ppJr.72� 2(�G��S /
By signing this form,you are stating that all information you hav provided is true and correct to the est '
of your knowledge. Unsigned forms will not be proeessed.
Submitting a false claim can result in prosecution. Date form was completed Ilo MArtG�l ?.0�2
Print the Name of the Person who Completed this Form: . �C4
Signature of Person Making the Claim: _
Re��ised February 201 I
. . �- �-- _. .-�:._ ____-. _ ..__. .�.__ . . _ .. _ . . .. _. ... ._ 1
St. Paul Police Dep�rtment for
Ramsey District Court
RECEIPT
Date/Time: 03/01/2012 19:49 Invoice #: 16121
Vehicle Plate: 5AR304/MN
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
888745224 $ 53.00
Total Amount Paid: $ 53.00
Paid by: CREDIT CARD
TVB COPY
. Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
. Make: 07 TOYOTA License#: 5AR304 CN: 12047044 Invoice#: 16121
Date/Time Released: 03/01/2012 19:49 Tow Charge: $ 123.95 � �
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: ELIZABETH Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
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. 1 acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
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?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature 5i2000