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. NOTICE OI' CLAiIVi rORM to the City of Saint P�1����esota
Alinnesnln,S�nle SY�dt�te;I66.05 stnles tlial " ...eve���person...irho clnims dmm�ges fron:nrrp nzur�icipnl�� l�n!!cta�s•e lo�e preserited to tfie
governing body q/lhe nu�nicipn(ih�iviliiin lb0 days afler N�e a!leged loss nr injw��is discoi�ered n ir�i�e�s��i,���rme,place, n�id
cu•cuntstnnces�hereof, nnd/he nnlnunl n/'compensation nr nlher re/ief rlemm�dec(."
. Please complete this form in its entirety by clearly ty�►ing or printing��oin•answer to each question. If more space is
needecl,�ttacl►additional sheets. Ple�se note that you will not be cont�eted by telephone to clarify ans�vers,so provide�s
much information as necessa�y to explain your claim,and the amount of compensalion being requested. You �vill receive�
���ritten acicnowledgement once your form is received. The process c�n talce up to ten weelcs or longer depending on the
natin•e of�yow•claim. This form must be signed,and both pages completed. ff something does not apply,write`N/A'.
S�ND COMPLTT�D FORM ANn OTH�R DOCUM�NTS TO: CITY CL�RI�,
15 W�ST K�LLOGG BLVD, 310 CITV IIALL, SAINT PAUL, MN 55102
First Name pQ�,"���L1� Middle Initial V Last Name �� ..
Company or f3usiness Name
Are You an Insurance Com��any? Yes� If Yes, Claim Number?
Street Address �� �SC�`� �ree�c f�a�
City�-�(, C�,t�,1 ` State f�,N Zip Code �����
Daytime Phone( - Cell Phone ( b' )�-��Lve��g 1'elephone t `
Date of Accident/ lnjury or Date Discovered /"`e�A`/ �c�n a(o Time S%0� fllll I m
Ple�se state, in detail, what occurred (happened), and why you are submitting 1 claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved �nd/or i-esponsible for your damages. _ ' �vk,,�,/
a- o c.�''�� - (3 I a�� �
t� v� �e l c�, ��tc'
� T:�v� c�! oW a c�—}'
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Please checl:the box(es)th�t most closely represent the reason for com��letin� this form:
❑ My vehicle�vas damaged in an �ccident �B'I(�y vehicle was c!amaged during 1 tow
❑ My vehicle was damagecl by a pothole or condition of ihe street ❑ My vehicle w�s damabed by a plow
�tc�ly vehicle was wrongfiilly towed and/or ticl:eted ❑ t was injured on City property
❑ Other type of property d�mage—please s��eci fy
❑ Other type of injury—please specify
In order to process your claim you need to include conies of�ll applic�ble documents.
ror the claims types listed below, please be sure to include the documents indic�ted or it will delay the handling of
your claim. Documents W[LL NOT be returned and become the property of the City. You �re encouraged to I:eep �
copy for yourself before submitting your claim form.
�PlProperty da:nage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills ancVor receipts for the repairs
O Towing claims: legible copies of any iicl:et issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of d�maged items
O Injury claims: medical bills, receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and retw•n both pages of Claim Form
I'�ilure to complete and return botli pages���ill result in delay in the handling of yoiu•claim.
All Cl�ims—please complete this section
Were the►•e witnesses to the incident? Yes No Unl:nowii (circle)
� Provide their n�mes, atldresses and telephone numbers:
Were the police or law enforcement called? Yes � Unl:nown (circle)
If yes, what department or agency? Case# or report#
Where did the accident or injury tal:e place? Provide street address, cross street, intersection, name of parl:or facility,
closest landmarlc, etc. Please be as detailed as �ossible. Fnecesslry, attach a diagram.�e ���y e; ��
��,,���t' -W�e �-�. Po�.►1 P� 1 y�_e I o�� �I��e. -�e �, � �- I
Please indic�te the am unt you are seel:ing in compensation or�vhat you would like the City to do to �esolve this claim
to your satisfaction. e �a ` a �
c � �
Vel�icle Claims—please complete tl�is section ❑ checl:box if this section does not a��lv
Your Vehicle: Year 14Qq M�I:e � � v�, Model ,�e,�-�-p� LJv�fs1.���o, Ev' !�'��
License Plate Number �R�, �S$ State�l�Color �l,ac,le �—
Registered Owner ����3C ��n.o�
Dciver of Vehicle '(" �
Ace� Damaged F;�vv� s, � � ►� S�, ov 1 t��1 1 c.� L o�'.
City Vehicle: Year Mal:e Model
License Plate Numher State Color
Dciver of Vehicle(City Gmployee's Name)
Area D�maged
Iniu�y Claims—l�lease comnlete this section ❑ checl: box if this section does not ap�Y
- 1-low were you injured?
What p�rt(s)of your body were in,jured?
Have you sou�ht medical treatment? Yes No Planning to Seel:Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss worl:as 1 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 att�ching more pages to this cl�im form. Number of ndditional pages
By signing tltis fornz,yor� are stating fh�rt al!information you hare provrded is true aud correct to tlre best
of your L•�roiv/erlge. Ui:signe�l forms ivil/not be pi•ocessed.
S�tbmitfiiig n false claim cart res�rlt in prosectrtio��. D�te form was completed 3TTl I�.
Print the Name of tl�e Pe�son who Completed this rorm: I���'1LS � �d�/�o-r
Signat�n•e of Person M�lcing the Clai�n:
Revised 1'ebruary 3Q1 I
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 99 VOLKSWAGEN License#: SRC658 CN: 12047044 Invoice #: 17026
DatelTime Released: 03/26/2012 18:29 Tow Charge: $ t23.95
_ Released to: OWiVER Storage Charge: $ 375.00
I
Paid by: CASH Admin Charge: $ 80.00
Released by: PERLITA Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 594.50
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: $ t0.00
Saint Paul Police Department. I acknowledge 1 will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 594.50
on this form prior to leaving the impound lot.
��� � —�1L�f � /J� �h 5 c, �
Damage and/or other problem: / � SlM:aS � j
� i. /JB-S� e.l�o C.��" /^'� 11'f c7(
Police Report made: Yes_No_ IF Yes, CN _, If NO, Why?
TO PROTECT YOUR RIGHT REPORT ANY PR BLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature ' � si2000