Johnson, Lydia ~�°°"' °�" AUG 21 2012
. � ,
N�'��CE O�' CLr�IIl�I FO�M[ to th�r��ifi3����aint �aul, Minneso�a
,tlinrresoltr Sla1e Stalule=166.0.5 sla�es!h«t "...eve�y person...ri�ho c(aims dnmages fi•om any tnrmicipalil}�...shall cattse tv be presented to 1{ie
governi�7g boc/v of the municipn/ih��ri�flin /80 days after/he allegecl loss or inju�7�is rliscoverecl n nntice slalin,�the time,�/nce,nnr!
circtunstn��ces�{�ereof,nnd the mm��u7t of compensntion or otlzer retief cl�nan�zded."
Please complete tl�is form in its entirety by clearty typing or printing��our a�isfver to each question. Tf more space is
needed,nttacli additional sheets. Ple�se��ote that you wilt not be contactecl by telephone to clarify�nswers,so provide�s
much information as necessary to exptain your cl�im,�nd the amount of compensation being requested. You will receive�
written acl:nowleclgement once yom•form is received. The process can talce up to ten weelcs or longer depending on the
nature of your ctaim. This form must be signed,and both n�ges completed. If something does not�ppty,write `N/A'.
S�ND COMPL�TED FORM AND OTH�R DOCUM�NTS TO: CITY CL�RK,
15 WEST I��LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �d= � Middle Initial�Last Name ����.5�� --
Company or Business Name ��(�
Are You ai� Insurance Company? Yes� If Yes, Claim Number?_��/�
Street Address �b ��'�� �� , �.�k `3 c�
City �.��v1 State �t� Zip Code�5 l�5
D�ytime Phone(_� - Cell Phone��8)�-�S� Cvening Telephone(� -
Date of Accident/ Injury or Date Discovered �J��� �� , '7-a��-- Time �`'°� n ��llll
�
Please state, in detail, what occurred(happened), and why you are submitting a claiui. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
' �'�C. w i a.. ,�� l'�
f— _ c � �o ►,�
T �
� r '?a � h
Please check the box(es)that most closely represent the reason for completing this focm:
❑ My vel�icle was damaged in an lccident � My vehicle was damaged during a tow
❑ NIy vehicle was dam�ged by a pothole or condition of the street � My vehicle was dama�ed by a plow
�My vehicle was wrongfi�lly towed and/or ticketecl ❑ [ was injured on City property
C] Other type of property damage—please specify
❑ Othec type of injury—please specify
In order to process your claim You need to include conies of�ll anplicable documents.
For the claims types listed belo�v, p(ease be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become tlle property of the City. You are encouraged to l:eep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates far the repairs to yotn•vehicle if the damage exceeds
$500.00; or the actual bills and/oc receints for the repairs
O Towing claims: legible copies of any ticket 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 damaged items
O Injury claims: medical bills, receipts �
O Photographs are always welcome to document and support your claim but�vill not be retu►-ned.
P�ge 1 of 2—Please complete and return botl� pages of Claim Form
r�il�n•e to complete�nd retul•n both pages t��ill restilt i�i delay in tl�e handling of yoi�r claim.
All Cl�ims—nlense comnlete this section
Were there witnesses to the incident? Yes No `�IIIilIOWlI (circle)
Provide their names, addresses �nd telephone n�m�bers:
Were the police or law enforcement called? Yes "� Unknown (circle)
If yes, what deparhnent or agency? ��'!� Case#or report#
Where did tl�e accident or inj�ny tal:e place? Provide street address,cross street, intersection, nai�le of park or flcility,
closest landmark, etc. Please be as detailed as possible. If necess�ry, attach a diagram. �
(�✓y �v�C.c�1✓\ � t.-ajcwu�'1 '����`La� S� r,�.,..�. C��c..��r� S�-
Please indicate the amount you are seekina in compensation or�v111t you wotild lil.e the City to do to resolve this claim
to your sltisfaction. T .�a��� 'l�Y�-e_._ �r;o �. �(�e��^��.{S-�� �a�' � v►�tr`�^�
-�'1� 5 ��nc,d,esn t as� w�2�
Vel�icle Cl�ims—�,le�se eomplete tl�is section �checl:box i�Pthis section does not apnlv
Your Vehicle: Year Mal:e Model
License Pl�te Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Pl1te Number State Color
Driver of Veilicie(City Employee's Name)
Area D�maged
IniurY.Cl�ims—Please complete this section C�j check Uox if th is section does not au»lv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No P{anning to Seek Treatment(circ(e)
When did you receive treatment? (provide date(s))
Name of Medic�( Provider(s):
Address Telephone
Did you miss worl:as a result of your injury? Yes No
When did you miss work? _ (provide date(s))
Name of your Employer:
Address Telephone
-� Checl�here if you are att�cl�ing more p:�ges to tl�is cl�im form. Number of�clditional pages 1 .
By signing tltis for�t,you are stating th�et all information you /cane provirled is true c�nd correct to t!!e best
of you�•k�zoivledge. Unsighed fo�•n:s ivi/l nnt be processerl.
Srcbmitting a false claini can rest�lt in prosecutiort. Date foi•m was completecl �����y
_ -
Print the Name of the Person who Cornpletecl this Form: � c�-� � lnws°�r
�
Signature of Person M�liing the Claim:
Revised I'zbruary 2Q11
- Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 01 TOYOTA License#: 073CUL CN: 12193608 invoice#: 139466
Daterfime Released: OS/14/2012 13:45 Tow Charge: $ 54.50
Released to:TOTO/DAUGHTER Storage Charge: $ 0.00 � �
Paid by: CREDIT CARD Admin Charge: $ 80.00
��
Released by. MC Tax: (7.63°!0) $ 10.26 �
I,the undersigned,have recovered the vehicle descri�,ed above. Subtotal: $ 144.76
1 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 r�port
damage and/or any other problems to the Impound Lot staff Total Charges: $ 144.76
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_Noi IF Yes, CN , If NO,Why?
TO PROTECT YOUR RIGHTS REPORT ANY PR08LEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000
ST PHUL IPPOIMlD LOT
630 BARGE L'!Y�lMIEL RD
SAINT PAUL, rPl. 55107-2450
651-266-5642
Herchant IU: 8006388144
Term I0: 0017348680880638014408
Sale
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(�f EntrY I�thod: Swiped
iotal: 3 144,�9
�i14i12 13:45:06
Im#; 890911 paar Code; 5231�3
l�rvd: Onli�x
Custo�rr Coav
TNfkY(YOU!