Danielson NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Min:�esota State Statute 466.OS states that "...every person...who claims damages from any municipality...shall cause to be presented to the
� governing body of the municipality 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 �L Middle Initial � Last Name �s„�n���Sb;� RE�EIVED
Company or Business Name, if applicable APR O � 2d�2
Street Address a�� �e���'j�.�cr ��G�,e,� �;�"�'�;���(
City s� . QC�,�� State /V�✓J Zip Code �/0�
Daytime Telephone �( i� ) �pg-�S�3 Evening Telephone b( �� ) �0����3
Date of Accident/ Injury or Date Discovered ���7( 1�" Time d 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 P ul or its employees are involved and/or resp nsible. I f
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Please check the box(es) that most closely represent the reason for completing this form:
O Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow
❑ 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
Q 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 you 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
�Tac al bills and/or receipts for the repairs
owing 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 njury claims: medical bills, receipts
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
A�laims —please comt�lete this section
Were there witnesses to the incident? Yes No U (circle)
�If yes, please provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (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 landmar etc. Ple se be as deta'led as ossible. If elpful,"attach a di gram.
�h � 3u ��� ��� � S� . C �r^9,tL ��.�WLCv� 1 v I i��� ra+� ��C✓lC/�
Please indieate 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.
Vehicle Claims—please comAlete this section ❑ check box if this section does not�_ply_
Your Vehicle: Year �pa3 Make :�, �,�, Model (�,��r�
License Plate Number 7 State�,/V Color���,�
Registered Qwner ,,��� S�p,4, .
Driver of Vehicle �t/f�
Area Damaged n//�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
- Area Damaged
Injury Claims — nlease complete this section "F,�,check box if this section does not ap,�ly
How were you m�ured?
What part(s) of your body were injured?
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 Telephone
`� Check here if you are attaching more pages to this claim form. Number of additional pages b .
By signing this form,you are stating that a[!information you have provided is true and correct to the best of your knowledge. Unsigned
forms will not be processerG Submitting a fa[se claim can result in prosecution.
Print the Name of the Person who Completed t Form: G `,e �,,�
Signature of Person Making the Claim: '
Date form was completed y����c�-- xev;sed Aprit 200�
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ST PAUL C►tatian# �
STATE OF MINNESOTA-RAMSEY DISTRICT COURT II�
IIII IIIII lllll IIIII IIIII IIIII Ilfil��ll .:
The undersigned,being duly sworn, upon his/her oath deposes and says: - II�II�I�������,-:,
-: ., � . �,� �` '�, � . � * :8 $ .8 � 43751 *
Date'of Offense +� '� � �1 �Time of Offense ��" ...� �
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,��� � E.�`� � �, � Plate � ��_ ,� '*�� ��..t� �
Veh.License No. .� .� � � - Year �4�- State �����Make ��'`�,�� Style �� ��'�' .. .�
� • - � Color , ���.
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Location of Offense�',� k� ��: ��" � ��x : '
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,VIOLATION: SNdW EMERGENCY St. Paul O'rdinance 161.03 r M
� FINE �53 0�
��,`, �� ��� ° (Amount includes mandatory state surcharges of$13�Tp}`'.
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Citin ��������"',-' Officer Citin � �
Officer �; .a � Number • ���� 9 ��,� � '
$* € . �Dept. �
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�] ost Night P ow � � O Day Plow ❑Plowed in Windrow ����`'
�,,, ( ) �Tag�ed Before Plow ❑Drove Of#:
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OFFICER'S NOTES �
❑NO PLATE'°,: VW`. `. ,4 , .
Citation can be paid at the impo.und Lot:Piease:read#he back of the citatio�i for�payment.instructiorrs: -
: . . _ . „
Cf�ATION�
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' `�Sl'PAUL TMPOUND LOT
830 BARGE CHANNEL RD
SAINT PAUL. MN. 55107-2450
' � 651-266-5642
� Merchant IU: 80063Ff0144
Tern ID: 0�17340000800E382144�9
' � Sale
zzzzzzzzzzz?909 �
Ah�f Entrv Method; S�iped .
iotal: � 219,5�
03�01�12 10,42;5� �
, Inv a; m0��60 l�pr Code, 5��99
�rvd; Online
Customer�oav �
THAMI YOU! ;
�. . �. - �
Saint Paul Police Jmpound Lot, 830 Barge Channel Road, Vehicle Release Form
• MaRe: 03 MITSUBISHI License#:7546GY CN: 12047044 (nvoice#: 16228
DatelTime Released: 03/01/2012 i0:43 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: SUSAN 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. I 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 si2000 �
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