Davison , '� R���:l�'�G;
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NQTIC�; OF CLA� �'Qr�V� ���,City of S�►i�t Paul, Minnesota
�titinneso�u S1ar�Srattefe 46&OS�ales tfrrrt " ...tvary persen_.Zrbo ctoi,ni dnm.t�jrnne arry manicipality...sha!!c:rase�o bs p�eaerveu't��he
gotc,•ning bocly of:!,s„�unictnrtll,y H-ilktn 1 SO dcys uJ18r ths�CagaA'iosa vr in,puy is tlitcovtred p nofics stnti�rylhe rinis,p/nce,atd
c;renmstnnce:l�ttr¢Of;��t/!d CmAt�Al of Co112rDerlSCft101t 0!'Othtt r8;te,r:!¢manded."
Please co�p}ete tL is farm in trs euticaty by clesrlr tyrin�or priutiMg ronr ans�vor ta each questian_ if more spact is
needed,�attscI�eddt�.ot�l sheet� Pkase aoh rist y�u�vlt!noe ba cont�eteA by#elapl�oae 4o clarity answtrs,so pmti ide as
mucD tnfirmetian�t.aeceasary i+n ex�lairs you�claim,aprl tRt smount of eampen�tt�n betng t+eqdt�6ted. 1'ou rrill racciHe t►
vrrittan actutowled�esunt unce yaur[arm i�rcaeiv�d. TGa proen�s cun tAke up ta ten wedrs or bn�er drpendieg aa Me
� n�tture ofyQUr clatrn. 'K'his fflrtn met�t be si�ed,and L;oth pe�es comp)etal. IPr,omethih�dats not apgly,write`N.'A'.
S�D CUN�PLETED T'C�RM AND Q'x�i'ER nOCUM�NTS TO: CIT`X CL�RK,
fl5�'V�S�'KEL�,4GG�L�D,3Z4 CITY�AL�,SA"C�T'�J'ACTL,�41N 55I42
FirstName � ��.. �- Middle Initiel � I,�stt�Jatne � f} V� SO t�J
Comp�any or$usinbss Namo ��� �
--r—
Are'You an lnsuranc�Companv" YeS l� (f Yes,Ctaim Number7
Sireet Addr�ss g 7 �I S w� 01�L �w rv �. ��v �
�;ry_ U !L K �(�1Z � s�ate M N z�p��c S 5 3 73
pAytime Phone 7(��S63 -�'?-L�Cell Phone 7G )St�- 32 EveningTetophonc 7{ 6�} St.�-�'s2
Date ofAecident/Iniury or Datt�iscavered � � / � � / 2 U 12 Tir.0 � � • U � am J p�ii
Please 3tnte;in dctai�,�vhat oceccrred(happen��,And why you ere submitting a ci�im.Pkas�indicate why or ho�v yau
feet t6e City of Saint P�ul or its cmplcyees ase involved a!id/or resiwnsibk for yoLr damages: M Y V C !-li G �E
"�A�S `0 W T D D v � T"t� IA S�/�"� i`; �'�` ;=i� �i; rJ� �• �/v �-i � n/ L _
i� �t �] 1� �i� � p 'N E ;� r �.= i� �. : t T �-� h n � N o i L �E l� k w �-1�l�i
c � 1-I Q � N o T �,� A � � � fo �� T �-i F s�� ��S /�L � � � �i- L � k Snrb
N �TL ` i MT �TTi� � ?l1N� '' '-� _ �M (r �' !✓ �
Pl�ase ch��k the bc>:(�s)that most closely represant ths reason for comptetin ths form:
es
❑My vehicic was d.amagr.d in an ace:dcat M;�vc�icle was darnageel durin�a taw
❑ MV Yf�]lCIC Wa5 d3ir18��a pothok or cond�on�f the stt�t G My vohicle w��amag�ed b�±�_�_..__ -
�'My v�hicl t v��8 v:rongfully towed:�ndfor ticketed " ❑I vr�s y.*►j ttr�c'en City rrox�rty
D�tt�er n'Po uf Pru:�'�nage–Pi�se spc�i�Y
fl 4ther iypa of iitji cy–plcasE spocfiy
In order tc�process your claim wou need�includz co»ies of all ann�icable docutn�eats.
- For the ctaims typas listed�Selow,pieFSe be sure to inc`.u�]e tl:e doeuments indicate:�or it will d�lay the h&ndlir.g�f
your claim. I�cum�:ms WIL ' f�e rete�rnecl tnd�ecom�tha proptrcy of tE�City_ You are encom�a�ed to iceeJ�a
ccpy for yo�!rself bc`a�submitting yaur�la in form. �
� Property��amage ctaims to a vehiele:two estimatas for the repnics tq your vchicle if the darnage excetds
�504.Q0;or:he ad�al biils and/or receipts for Che repAirs
O Towir!g clnims: (e�ible ca��ies of any tickct is3ued and a copy of the impound lot reccipi �
. O Oihar pmperty dama�C clt►ims:two repair estimat�s ifthe de�g�e ex�eeds'�SOO,t)4;csrtha actusl bii;s
andlor recei;�ts for the t�nnirs;.detailed list of damagtd iiems ��
� O Injury clnims:msdical b►[In,t�eceipts
c� Fhotogra�hs are always welcome'ta dacu�nent and suppor�your cla i�c,bert wiU»at be t�etunxd.
T'sge 1 of 3–Ptaase complete ancl retnrn botk pagef:of Claim Form
i � r nt�! 'fAi QCn�f_i{�f'—� G�l tlJ.I/tr: ? � ���17 'fi 'u�:
. . �__ __.,.—_._.._. - ,.,,n��,,.�� �_.- � . . � -
�aisure to camplete a2�d ��etx�ra hoth pages wilt rescelt iu delay�n sl�e hanrlit�a�af yoc�r etaitn.
�All Clairr�s—t�e�.se;;omp)cte thi�section
�Were thvre witnesses to the incidenY� Yes Na nk ^ (cireie)
' Provide tt�eir names,addresses and ttiE.phonc nurr►bers:
Were the�olice ar la�N enfoiroe�nent c�iled? Yts 1� L'nknown (circle}
If yes,whAt department or agoncy?� Case#er rep�rt#
Whe��e did ths xccide.�t or ir:jury tqke�lace? P�nvide street addi�ess,eross street,intersect:on,name of��aek oc faeility,
closcsi I�ndmark,etc. Pie�se be as detgi!ec!as possible. If ncc°ssary,aitACli a diagram. C I� R T OW� Q
Wkl � r� Rt� RKFD v�r � �f. � oZNF2 �f p/�{t;�41 st ,�Nn __T1a_YLa�, kVF
Please indicate the amount you are seeking in �mptt�s�tion or`khat you�ueuld Iii;.e the Gi*.y to do to rf:sotve this elflirn
to yuur satisfaction_L /� C; �A �b 7� 1-{ t''�t� � I F !h S i I-! r �L�t {��/v G It/v LS �
(,� N D fi 1-t � (��� � r a r_ �_1�.T l� G N o �r� �-n; I� R r P!� s :__�.�
' l�icle C�ims—nL:�se com,�lcte th�s se�on ❑ chxk box i this s�cction dxs no:ap�ly
'�our Vohicl�: Year�6 Make_N T S� /� N _Model 2 p O S X � -3Z
LicensG Plato Number T F R� �� 2 State M/�Color_�� F ��! ,
Registececi O�mec t t7! � �(���r S �?/k� _
Driv:.r of Vohicle C 0�, t 1� R 1/ �S D I�
Ares I7�maged b�L p!�n/ ; C N (r t N�
City Veh;cte� 1'ear Make Mode!
Lice:.ise Plate Number 3tace Color
DrivMr of Vehicle(City Emplvyee's�iarne)
A�e� Uaniaged �
Iajurv Ctatms—r►kas�cum�slete thfc aeeti�n �chec�box if this seciion d�cs�ot arx.+ly
How wcrc you injured? __ _ __
What p�rt{s)ofyour body were injure3?
Have you sou�ht me�jical vcatment? Yes No Planning to Sxk Tteatment(ci��:le)
w'herl did ycu receii�etreatment? (yrovide date(5))
Name of Med��1 Pr�Jv ide;(s):
Address ,Telephone
Did you iniss work as a result of vour injuty? Yes Nc
When did you mi�•.vocic? t;providecEate(s))
Namc of your Empfr.tiyer:
Address__ _Te!�hone
�Check hex��if yo�i Are s�ttacl�inb cnore�ages to this cIaim form. Ni�mbe*of�ddIttanal p�ges�.
By si�►ning this forrn,yor�are stal�ag t1eRt r�ll informotion}�ou htrve provirlecl is true ancl cor�,�ect to rl�r.besi
vfYortr knotivledge. CJtrsigne�Cfor��s wift not beF�r�cesserL
Sr�bmitting!�fn/SE el�tifn Ca�i 1"�Slr,►t in prnsecu�io.re. Date farn�was cam�leted � � �2 �2�12
Pr�nt th�.Name of:he Person�v lto C:omplefed ihis Form: C U � � � � � �/ fi .� � ,�l
� �
Signarnre oirerson Making the Clt,im: t�' -�, G�'(�,✓'
Re„�st���rh��ay 2oi� .
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�d
�'. �av� G�k a�t�e � ��►e i nvoic.e ���►} 1 F�GiQV�� v,,�,�n �
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('eG,a"Q�e� r1 y veh i c l.e �S well G�s �-�� ���e.T � { �corh �-t,� �,r�a,r
�hb,� kb whi�h Z h� ou9h� �-�� ��hiG 12, . � ,mGy h� � �-V
� �k� ��.e f
�� Pai r �he v2hi ��2 �Ut ��e�, in w�►�c. �, �-�s.� ^l. S �all c-on � � c�
�-�.e. Lii-y uF S}. �u�tl f.L ���2�n� �� k��a� 'Loy►'1 ��e✓� Sa�iDn, � um
SU-1r����j c.oY�nPtnsafi io� �r t�,2 �►�ac�nt �F � �10,� 0 �-�r �-hx. f,ePa�� d� r+y
J�ti,;l,le.
. Saint Paui Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
� Make: 96 NISSAN License#:TER231 CN: 12U47044 lnvoice#: 1658� �
Date/Time Released: 03/01/2012 22:38 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: CHANTRES Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehic{e described above. Subtotai: $ 219.50
I will check the vehicle for damage or any other problems that
may have occurred whife 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.
1�►�� _. � � C.� L�, h r,J i 5� C o n� i�ni�y
Damage and/or other pr�lem: � 1 �� t L
�(� ^� -j'1,�, 2ru ti �`e, in��r -�-�,� �poc..,rp� �-�{�� f� ^+� ,�H�rn�/J � le�k��h Oj�
.
Police Report made:Yes_.No_IF Yes, CN , If NO,V�Jhy?
T PR TE T Y R RIGH R PORT ANY P BL M AM E BEF RE VING THE LOT
� 5/2000
Signat
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