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Wise _ _ _ � NOTICC OF CLA�IVI FORM to the City of Saint Paiil� IVlllll�� ���3`,:°��� �1/irr�7esotn.S�nte.S7nlu(e=166.05 slntes lhn� " ...evei��persori...u�l�o clniurs dmnnges fi�om rutp�rt�u�icipnlrlp...shcd(catrse!o be p�-esented to ll�e go>>erning ho�h�qFtHe nuu�icif�alih�ri�ildiin l80 da}�s nfle��Ihe alleged loss or injw��is discoi�ered a rfotice s�alirl���e ti�e,�'pl�c�''�`��ad cii•cu�nsirn�ces Ihereof, nnd the nmoiu�l o/�compensalion or nther relre/'rlemnnded." Piease con�plete this form in its entirety by cleai9y ty�ing or printing yoiu•ans�ver to each questi�.�1 I�'f���S��i�e is needed,attach addition.�l sheets. Please note th;�t you will not be contacled by telephone to clarify �nswers,so provide as much information as necessary to expl��in your claim,and the amount of com��ensation being requested. You �vill receive a written acicnowleclgement once your form is received. Tlie process can talce up to ten weelcs or longer depending on the natw•e of your claim. This form must be signed, and both pages completed. If something does not apply,���rite `N/A'. S�ND COMPLTTrD I'ORM AND OTH�R DOCUIVI�NTS TO: CITY CL�R1�, 15 WEST K�LLOGG BLVD, 310 CITY IIALL, SAINT PAUL, MN 55102 First Name ��'il�"'�(� Middle Initial L Last Name L•�:15(.�,t Company or I�usiness Name �/�- Are You an Insur�nce Com��any? Yes /�' If Yes, Claim Number? Street Address ��'(,� j��'1(�=�F�,� S�/G'��� City �.�1"�c.(._ State �`1 Zip Code J .��Z Daytime Phone ( )��'��%r Cell Phone(G�),�-�Gvening Telephone( ) - ! i Date oi�Accident/ Injury or Date Discovered (�'",i�— �L Time 1� � am /pm Ple�se state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or ho���you feel the City of Saint P�ul or its employees �jre involved and/or cesponsible for yo�ir dam�ges.'�GC..f( Cc.r4S C� 0� � f j2 �D S�' C� EI(Gt;J !1�' � � �� w��d��,�' � t� 'F2c��n � C `" � y�A-�Ktic T� cK��" u�h�y/t l� = c.�,° � - 14u� —�o` C�t,� l< ' it) c�. i �,, �' ' �t� �� �% �� - v� � C��,/y �C� c� —A- � C�� � � ;�_ � � � c -'� 41t / L -� � �c1� C� Please checl:the box(es)th�t most closely represent the ►-eason for com��leting this form: ❑ My vehicle was dam�ged in an �ccident ❑ My vehicle was damaged during a tow ❑ My vehicle was damagecl by a pothole or condition of the street ❑ My vehicle was dama�ed by a plow �ly vehicle was wrongfully towed and/or ticl:eted ❑ I was injured on C�itY p�roperty thec t �e of n�o�ert d�ma e– �lease s�ecif ,fj. �rQ' ��� � �f�-1��t.c.S �'h'f( '� YI 1 I Y 8 I I Y���—__— �–� ^ , � C"� ❑ Other type of injucy–please specify In order to process your claim you need to include copies of�R apnlic�ble documents. ror the claims types listed below, ��lease be sure to include the documents indiclted or it will delay the handling of your claim. Documents WILL NOT be returned and become the property ol'the City. You are encouraged to I:ee�� a copy fior youcself hefore 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 O Towing claims: legible copies of any ticl:et issued and a copy of the impound lot receipt O Other property damlge claims: two repair estimates if the damage exceeds $500.00; or ihe actual bills and/or receipts for the repairs; detailed list of damaged items O Inj�uy cllims: medical bills, receipts O Photogr�phs �re always���elcome to document and support yow�claim but will not be returned. � �/,��� i- P�ge 1 of 2–Ple�se co�nplete a�id ►•eta►-n boil� pages of Claim Form .,� �� s �-�,�-� ,�o�cc�� �c�-�sc c�41 1 5����r,,,,-�- Pd��c��- �-1' � z_� 6 ,y� � �s � _��-s-��� c���= � � � � d =;,� _ : :, ' r�ilure to con�plete and return botl� nages«�ill result iu delay in the h�tndling of your cl�im. All Cl.�ims-nlease coml�lete ihis section Were there �vitnesses to Ihe incident? Yes 1�1 Unl;nown (circle) Provide their n�mes, addresses �nd telephone numbers: Were the police or law enforcement called? Yes No Unl:nown (circle) If yes, what department or agency? Case# or report# Where did the accident or injuiy tal:e place? I'rovide street address, cross street, intecsection, name of p�rl: or facility, closest landmarl<, etc. Please be 1s detailed �s possible. f ne essary, ��t���� ����������,,. �Y���-.�r� _ ���wc�� � � � s f'lease indicate the amount ou are seel:ing i com��ensation or h�t ou w uld lil.e th�City to do to resolve this claim to your s�t�sfact�on. �AY/ �2 �TUc� ,� l�y. ?6 �A.��'v� �C;l/iv`T .15� ll� °d �Qp/ �c� �►���c �� c��r���.,ti��- Vehicle Cl�ims- please com��lete this section ❑ checl;box if this section does not au�ly Your Vehicle: Year �Lt SS7 Mal:e �3�'U Model ll�}� License Plate Number State �� Color ��� Registeced Owner C(�2-�,�5 r✓t�t= Driver of Vehicle �- � Area Damaged �/�t� ,P�tqrt City Vehicle: Year�`-�- Mal:e �— Model � License Plate N�.imber���_ State Color Driver of Vehicle (City rmployee's N�me) Are� D�m�ged Iuj�u•y Clai�ns-�ile�se complete tl�is section ❑ check box if this section does not au�lv I-low were you injured? h,� What part(s) of your body were in.jured? Have you sought medical treatment? Yes No Planning to Seek'I,reatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss worl:as a result of your in,jury? Yes No When did you miss worl:? (provide date(s)) Name of your Cmployer: Address Tele>>hone � Check here if yoii �re �ttaching mo�•e pages to tl�is claim form. Nwnber of addition�! pages �� Ey signi�rg t/ris fnrr�z,ynu «re stati�rg t/�nt�r/!i�tfo��matio►t��nrr /rrrne pf•nviderl is trrre a»d correct to 11re Gest n/�yoru•Guo�vledge. U�tsigned_forms ii�i//�rot Ge p►•ocessed. Subntitting t�f�rlse clai�n cait result in prosecutinie. Dnte for�n was completeci f7'��� � Print the Name of the Person who Completed this I+orm: �'u��S C.�Jt S(,,,-� Signature of Person Malcing tl►e Clai�n: C�C;d -� Revised I�ebruary 201 I _ _ _ _ ;�: Q �*os; Front ;�; � ' � � ��� ,� �._ , � � . � , � � � � r�. 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' �`1 � � p �' m �, D , �. � I'b m °` l� 3 � � • � � cn � � x . � Z m � C � \ ° � � o �l � .�. �. � � � � D � � • �y ,.. � p f^, m 6`� G O 2 � • � � ,� � � _ s s � � � k_ t ; € �, ��c�. � � �, �� d - o 1 D ' ° � y N � ' �' � p 3 ; o� ` � <� . ',. . . .. ' � � ' � ^ � m � D� • 1 . . �� : .. � ' � 1 � � � m . V � O � °m o • � . ("� S m a m c� L �O Oy � D Z c < � � o o � ° . � �, � � m i� D � r � � � o a Z � � n � � � � �1 o z °m � i � _ � � � � < < � �, s ° � i .. � �� � � � �� , a a �, ��„ � � o o ' � � o ° o • m , i i � � , I � I I � N ! � � J � I.L , , � - - - - - - -_--- - --- - ------,-- -- W � ' _ � F- ' I ' � �_ I . i l i i i � � � ; ; ; � � I , � ; � , � � ; ; ; � i li I i ' I � I � � � � � I i � I UJj � W ,J � �_ � I J � I� ' Lj J U � I J � I� I �y I JIUi� �'J I G F- , � IQI W ' Q O F- I J Q � WIQ OII- � JIQ ; � IWIQ , o] � X miH � � = F-- [0 CC � X � o] iF � 2 'H [0 � X [0 ' I- � � S I- �, a ! IQ- ��nju�i�� 0 010 �0 Q ; a �� H ' in r�n� � �o O �� � � al � in u�i ��� o �lo��� � � i 1 �--- -- --_ �- --- --- I -- I - � -- -- -~--L = -r I ' i I � I I �� � Z Z Z � � j i � I w l w w � � � � � � d Q Q � � � � I � � ■ ■ r i ('�,� ,� � M ,, � , � � ' i � � ' 00 � � , m �-° O ,�� � � w � :� t� � ol � p � � oi � Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 87 FORD License #: YAZ8484 CN: 12146432 Invoice#: 1384�7 Date/Time Released: 06/22/201 2 1 9:29 Tow Charge: $ 54.50 Released to: TOTO Storage Charge: $ 0.00 Paid by: CASH Admin Charge: $ 80.00 Released by: LARRY Tax: (7.625%) $ 10.26 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 144.76 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: $ 144.76 on this form prior to leaving the impound lot. i Damage and/or other problem: b'�1�TC� �� F�����_ FRc�►'i �St=.c�t�' D�C-:�_ o f=FTvc��cx:�( �����' T� FR��.~�- Stt�i�� �'.►�1 ��ec�� �SC=iy aC� �-o �� i�rrt�'� Police Report made: Yes_ No_ IF Yes, CN , If NO, Why? TO PROTECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Siqnature �� ���_ si2000 Page 1 of 1 � � v r.'-. . :�:a. _�`+- ,:,a I � . L ;��, ;, {r�"..� �. ±'�:� ;a, _�v. , 4 � � Page 1 of 1 rl � � � 0 � Page 1 of 1 P 7, - �; �� �� ��� f ���E . t fiyi i �' ;� .•� ;' �[ ? -�i : ii i .i ���� ' � �� � ����� � :� �a„ � � �.; ��c. �'�� . . - t i a:a� � � ��' � �� � �'� ' � � "�. � ���'�'s������.������h� �'��,,,.���� :�.: Page 1 of 1 ���}�'t 64-�c� ?—v �/t4�1 /`�-�r5�v�-�' � 3� 6� ,�:_ ��Q�� �KS -1--�c�(,c�'C' �( ( �o �^ i :3 �:�,. 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