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Nelson, Rachel . �� , � NOTICE OF CLAIM FORM to the C�� Qf S�a-int Paul, Minnesota �._... . Minneso;a5tnte Statute 466.05 states that " ...every person...who claims damc� (� i ipality...shall cause to be presented to the governing body of the municipality within/80 days after[he alleged loss o1-r��N,��d 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 ��C.�'��.`�,` Middle Initial � Last Name �✓��CJ f� ��E�� Company or Business Name, if applicable MAR 2 � 2��2 Street Address �Z-�--6 �r^-►�j'1�'�,� � J—f V � ��'� � �'+�� '+�-� City �G�.�� V`.� State �1�1 Zip Code � �O C.. Daytime Telephone �( � � ) g��'��3��. C Evening Telephone (_� �°�<►'�i� Date of Accident/ Injury or Date Discovered e�� I� Time � d am /pm(circle) 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 employees are involved and/or responsible. o n -�ti r� n;q h-� � �r�r, 1 �Z��2 r�Y v�'b�►c 1�. Vva,S t�W�- �-�c�r c�,n� �n�p.r'9u�c.Y Snaw �e�,Ov�.l. Th�. Stre� :r I�v�. o� (r��.�s�,d..l� P��.. ;� �-�r�t Prr-u�,l� i S v�. (�`i 9►�s-� �1 ow St1'��t,�t c�.�d.,� w�r,k -1�c� Ch�,t'C,h °�a,� n i 9 h� ��,� �'1a� hdMe. �r�wnd�. �—�'�o� �a.n �et'e, Uv� f�o 5�9nS a.lo►�� h�. f dd,, ind.��r��1 -t�.cx�; `�C'�o.,,�!�i t 6�: Pf�r-ic�� h�.t'e.. L �..�S� d.on'� �e� -� �xz.t�h �h�. new5 u�l�, d;►c�.n� I�;no w �b a�,� -��. G�Y;S ��t�n� 1 i S-� �-�h�,� 1e�.�. �.o�,n b z o n� So -�he,��, �wc�S nn w�.�r .��r� m� ..�� rcndw ��(; -��,►� �v.a.s� �. �r�nw 2.r��u,GY. °�en �. Wi�1C(�, t� iC►�� 1'1 't�l-� Mf1�r'r1i n� ��+Gc��l1�� Uv� Sv�.PP�1@,.�' � dt7'v�!/� d� ZII��O��S �J,�'. Please check the box(es) that most closely represent t e reason for completing this form: Lh;G�90 �nc�,.Z !`� ❑ Vehicle was damaged in an accident � Vehicle was damaged during a towg�y ❑ Vehicle was damaged by a pothole or condition of the street 0 Vehicle was damaged by a plow�� Vehicle was wrongfully towed and/or ticketed � Injured on City property `�S H� F ❑ Other type of property damage—please specify__ �� p -fi ❑ Other type of injury—please specify 3 � � � O Other type not listed—please specify _. . � In order to process your claim you need to include copies of all apnlicable 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 �7 rt'F T provide additional information depending on your claim. �� O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle,�t�h��; � .� , actual bills and/or receipts for the repairs � � � }� � j C� O Towing claims: legible copies of any tickets issued and copies of the impound lot receipt �tl' O Other property damage: repair estimates, detailed list of damaged items ri 7 � �`�6 � O Injury claims: medical bills, receipts � � . ��, �� 1 `y�O�Photographs can be provi de d but wi l l not be re turne d. �, �� (�(` � ��"` J y�n� ��I�t'Y� °°' '�'y� P a e 1 o f 2 —P l e a s e c o m p l e t e a n d r e t u rn both pa ges of Claim Form �,�° v� � (�'� � 41� �- g F _, cr �}-'`�'"�};��'Yy l�l(yjaJFailure to provide a completed claim form will result in delays in processing. �' � � .�, � 2►u p� ,�� a��-t �w �� 5^�� ° ' n N� H�� .� �u � �. �� 'Y'�� S'`1�- �'� �� S"o`�''o�_ �., ! v rr cr'P .�C�;w``�'-}° �.�.�1 ��..r �.. `��E- o�"�6 ��°;^� ��S"'�� -'�Sd'�n �.1�ba.1 �S�ro �,�. '�u�n q c�C' �w �p�J�� a Notice of Claim Form, City of Saint Paul, page two All Cla�n.s–please complete this section ', Were there witnesses to the incident? Yes No Unknown (circle) i If yes, please provide their names, addresses and telephone numbers: ' Were the police or law enforcement called? Yes No nknown (circle) If yes, what department or agency? Case# or report# Where did the accident or injury take place? Provide street address, cross street, intersection, name of park or facility, closest landmark, etc. Please be as detailed as possible. If helpful, attach a diagram. �Z.� /"��,�'�h�l I �1-v� �ri�.;nt Pp�u.i M i� ,�S I D L v '��S 1 cTC�t,-��or� i S f i 9 h� r(1 E'.k-C -�O �a,i�- P�-�� 1 C O I I 2°I�2. 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. Z WG;�.,I c�. i IC-�,' i CUC�.I r1�- 9� `�`�� 2�°I �-�v r -th�. �rn��v�,��. I�ruc��,_ ti-'� i�f �. c:v�,��,, ��.--� Sor.�� c�f- ;-� kXx.c IC -�.hc�.-t v�.► be. �n E, oo a ca.s ` `S � �I�'ea cA.o ' aU� � �� o�u��w Vehic e Claims– lease com lete this section �check box � this section does not a 1 Your Vehi le: ear �a Mak M�' Model /"�yS�► Li P1 ate iiv i1� e � D 'ver of Vehi o�, rea Damaged ity Veh' le ake ode + ice P1 er t e � e Emp e's Nam r amaged In,Lurv Claims please complete this section l,�check box if this section does not apply How were you injured? What part(s) of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) VVhen did you receive treatment? `�'r (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 Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages B}�signing this form,you are stating that a[l information you have provided is true and correct to the best of your know[edge. Unsigned forms wil! not be processed. Submitting a false claim can result in prosecution.p � �C� Print the Name of the Person who Completed this Form: 1\�-C�'1�,`�.� �Q� Signature of Person Making the Claim: �it"f�—�� — Date form was completed 2-�/ �� _ xe��5ed Apri�zoo� 3�a3� � z. This claim form is being returned without having been set up as a claim for the following reasons: Failure to provide a written description as to what happened and why a claim form was being submitted(page one). �Failure to provide the proper and required documentation (page one). Failure to provide a date of accident or injury(page one). Failure to indicate the amount of compensation being sought(page two). Failure to provide information about the vehicle involved (page two). Failure to provide information about the injury claimed(page two). Failure to sign the claim form (page two). Failure to print the name of the person who completed the claim form(page two). �Other: _��)lA�-� �fl`� �GP�t-��' �T�C�,�-�- Please retum the completed claim form to: Office of the City Clerk City of Saint Paul 15 W. Kellogg Blvd. 310 City Hall Saint Paul, MN 55102 If you do not return the completed claim form with the appropriate documentation or information completed, then a claim file will NOT be established and an investigation WILL NOT be done. In other words,NO FURTHER ACTION will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances. � . � Saint Paul Police Impound Lot, 830 Barge Channel Road, vehicle Release Form Make: 00 MERCURY License#: 720HKE CN: 12047044 Invoice#: 16491 Date/Time Released: 03/01i2012 17:22 Tow Charge: $ 123.95 ,--�_� Released to: TOTO Storage Charge: a 0.00 , ��,,' ,, ��l. .._„ t � Paid by: CREDIT CARD Admin Charge: $ 80.00 �� Released by: BECKY Tax: (7.625°/Q) $ 15.55 � � , „ �: I,the undersigned,have recovered the vehic!e 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. I acknowledge I wili report damage and/or any other problems to the I!npound Lot staff Total Charges: $ 219.50 � on this form prior to leaving the impound lot. Damage and/or other problem: i Police Report made: Yes_No_IF Yes, CN , If NO, Why? TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature si2000