Kleinboehl -�-, . � .. .
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NO�'�C� OI' CLA�TVI �OIZM to th� �����a`�°�►�t Pat�l, Mii�nesota
�__. ._ ._ - -._._
. li�arresotn Stcrte.Sta�ute=l66.0�s•lates lltal " ...eve�J�person...ir/zo clniins dmm�ges fi•on:nm��rii�nicrpa(il��...shal�'cnus•e!o be presented lo Ilie
goi�e��nrng boc(v o/�lhe niw�icipnlifi lYfl�lN? lb0 days nj�er�he a!le,;ed loss nr injm��rs discovered a notice sialirr,;1/re time,place, and
circumslnnces Iher•eof,ared tlie nmoun!�/�conit�ensation or o�{�er relief demanded."1yvJ [ � �O'��
Please complete this form in its entirety by clearly typing or printing your answer to each que�4�t✓t1,��n��ace is
needed, attach additional sheets. Please note th�t yoa �vill not be contacted by telephone to clar 1�n�s��e��s ovide as
much information as necessary to explain your claim,and the�moimt of compensation being reqiiested. You will receive�
written acl:nowledgement once your form is received. The process can talce up to ten weelcs or longer depencting on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
S�ND COMPL�T�D FORM AND OTH�R DOCUM�NTS TO: CITY CL�RK,
15 W�ST K�LLOGG BLVD, 310 CITY �IALL, SAINT PAUL, MN 55102
First Name/�I�Xp,�'1��� Middle Initial � Last Name ���P.i✓1�UP_�l� --
Company or Business Name
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address �j�� �'('�,�, �J�
City ��. �C�v�,� State ��\I Zip Code S�D�
Daytime Pllone (_) - Cell Pllone (�)��iS-OI 30 Cvening Telephone(_� -
Date of Accident/ Injury or Date Discovered J�����5� 1�I �vl�. Time �;vv Ill�plll
Please state, in detail, what occucred (happened), and why you are submitting a cl�im. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or i•esl�onsible for your damages. % �,,,�I�Ced o�-I- �r�
�� �-�.E ��f,�nA �U A� yt� v✓l v �a� I../L.���.. �ia�ST f No� �n li✓1C��In �,P�✓Qe✓1 V�L�i/'il,. �'/�'ti,l�".�
� �' li✓e i � W
��-�e ek. 1 �,.�r,�� Nt�T��✓Ei'1 a,�l l.r ✓l��-1-�cC � ��, S 4✓�d �-L,�r� �✓e/'� l�D S�e�n
�.��,-�� d-�< <,f S 7��U( �1/�C' UC� [3(_S -Je(�� �� e� �rl L�/�rn�/1 n✓1r � �S V2�fY f� Vit�� $
�'�-�G�-��� +U 1��«r�.[. � r'1�S S P� a d.e��i U�-' �J��✓'� a-��� �c� �v I�i�/ I Y�-/.7�. L
C� \ �r-• !. ` �. G t ,
Please checl:the box(es)that most closely represent the reason for completing this form:
❑ My vellicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vellicle was damaged by a pothole or condition of the street ❑ My vellicle w1s damaged by a plow
� My vehicle was wrongfully towed and/or ticketed ❑ I was injuced on City property
❑ Other type of property damage—please specify '
❑ Other type of injury—ptease specify
In order to process your claim you need to include copies of�11 an�lic�ble docnments.
Por the claims types listed belo�v, please be sure to include the documents indicatecl or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to l:eep a
copy for yourself beCoce 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 actua( bills and/oc receipts for the repairs
�yl.Towing claims: legible copies of any ticl:et issued and a copy of the impound lot ceceipt
O Other property damage claims: two repair estimates if the damabe exceeds $500.00; oc the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injuiy claims: medical bills, receipts
O Photographs are al�-vays welcome to document and support your claim but will not be returned.
Pabe 1 of 2—Please coinplete and reti�rn botli pages of Claim Form
_�
� .
� Failure to complete�nd ret�u•n botl� p�ges will result iii delay in tl�e handling of yoi�i•claim.
All C1�ims—nlease com��lete this section
Were there witnesses to the incident? Yes No � wn (circle)
Provide their names, acldresses and telephone numbers:
Were the police or law enforcement called? Yes � Uni:now�l (circle)
If yes, what department or agency? Case# or report#
Where dicl tl�e accident or injtny tal:e place? Provide street address, cross street, intecsection, name of parl:or facility,
closest landmarlc, etc. Please be as det�iled �s possible. If necesslry, attach a diagram.
v�l ��r�<c��✓1 h��we P� � \���rj� S�- � U�L�df i� �-
Please indicate the amount you are seel:ing in compensation or�vhat you would lil:e the City to do to resolve this claim
�to our satisfaction. l_ wo�..l2� l�K.P_ -j-� b� C�,�h,,�{'S�e.�- �r� �}-l-.Z v�c�✓����
1�i � I��=k-��5 �nc ���U �r�S �-- .�,�
Vel�icle Cl�ims—ple�se complete this section lK1 checl:boa if this section does not apply
Your Vehicle: Year Mal:e Model
License Pl�te Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Ye1r M�I:e Model
License Plate Number State Color
Driver of Vehicle (City Cmployee's Name)
Area Damaged
Injury Claims—Please complete this section �chech box if this section does not apply
Ho��were you injured?
What part(s) of your body were injured?
Have you sought 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 a result of your injury? Yes No
When did you miss worl:? (provide date(s))
Name of yoiu� Employer:
Address Telephone
�Checic here if you are attaching more p�ges to this cl�im form. Nwnber of additional pages �
By signing t/ris form,yor� are sttrting tlaat rcll information you kane providerl is true ati�l correct to the best
of yoiu•l�rto�vledge. Unsignerl forms i�vill nnt be processed.
Srtbmitting a false c/aim cnn result rn prosecutiojt. Date form was completed ���L��j�,
Print the Naine of the Pe►-son wlio Coinpleted this Form: ����,n�v �(` I���.r��P_��
Sibnature of Person Malcing the Claim: �',
Revised I�ebruary 201 1
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
_ �
Make:89 CHEVROLET License#:881JMR CN: 12193625 Invoice#: 139468
Date/Time Released: 08/14/2012 15:54 Tow Charge: $ 54.50
Released to: OWNER Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: B�CKY Tax: (7.625%) $ 10.26
I,the undersigned,have recovered the vehicle described above. Subtotai: $ 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(eaving the impound lot.
Damage and/or other problem:
Police Report made:Yes_No�IF Yes, CN , If NO, Why? ����u' ��c���' h���.�-
TO PROTECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signatur%�c-�iii�y'e;'�-- s�z000
___..... ______ .�
ST PAUL INPDUtY�li. ':��
g�BpRGE CHPNNEL k�
SRINi P���-�2 7-2450
Ikrchant ID: �'�1��14908
Term ID: 001734
;
Sale
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Vi�p EntrY Method. Sai�ed
iotal. S 144.�6 '
08�14i12 15�5Zc�
Im �; (�6615 Pvar Code: �iZ314 .
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