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Johnson, Russell FtEC�lVED � � � OCT 2 3 2012 � �! ��RK NOTICE OF CLAIM FORM to the Cit�o�f��aint paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipaliry 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�V�� ! Middle Initial t" Last Name�>(1 S�ll'L. Company or Business Name, if applicable StreetAddress�t-�(�t�ti`d�1�. ��t�'�r� °_"�C�}�,�i��—� 1.�--�- �� fw�� Pt��t, �t � �'t� ��1►�1 City �fi - p('t�. � State m�) Zip Code_�--.�-� Daytime Telephone (��) �1..L �C - �S��? Evening Telephone (��)�Le_(Q --R�l � � Date of Accidend Injury or Date Discovered l ��(�- �C��_ Time C '. � am�(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 Paul or its employees are involved andlor responsible. � � _ C L �L ` , j-�- ^�� S �►�n � d � � � � �1 �1 c� c� � cc�� _ � � s. G�' � i �- C? �C ��L' � �l c� � '� i ci � C�� c ,c.' ; - , . ,i �t�p�i £s �� ;¢.-1'�iL � CC<<�11�-�r- i�C �Q.��k :SfzlYlC ��C � ��'\, yn6�k.,..z Please check the box(es) that most closely represent the reason for completing this form: ,,,� � Vehicle was damaged in an accident � Vehicle was damaged during a tow ❑ �Jehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow I�Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property ❑ 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 anplicable documents. This is a general I 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 act al bills and/or receipts for the repairs Towing 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 Injury claims: medical bills, receipts O 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. �ttn �g h�h� � �e � �`�c�.��e.�1 I� � . 0��'�2�> � .i �l�c�� - "�°'�i l� ct� e +(Y��` c c'�.�Y�' �cU��,c�� '�n _�c�m m�+- --� r 1z sS -��'t-'11 J �� '1(��!� � }-t i�CL.�� I��C� �. `� �c..r1 c�c�..� ��r n'� ) . `�"S�- e�) c� �� p� �,�`ri� P�v�� c� r.� �—r� c� � ��,�.��,�� c� �t c��S �{e� -�.� C��1 c:_.-t-h`� �t i 1 S�o�-�,��c�ac , `p c t-� b-E- � c� �.� ss �k�r��r� �{ ��-�S �-t=� �-s�- �IZ �� (��c� � �_a c�— S�mm*�- '�-v.� ti `�_ cct`i� � t"+1 c�v�- V 2,1��\�S �l ,�S �,� 1,,�;1'1 i c�"1 P�4�� c�-�S � g ��S T�`� �C�,\ ��'�� 'c Q S�►�-� � r v i�-t- h � C,�-c �� C��'�'�-- � �� f�c� I, ".�- � h��.�s.� . ..� m c�� -t �� C I E�. s --�� }.� ��11�� -�C � h��r, r'��`�c��c� � c� � I�-� s-1—r� �-i� �-- Q o�� ;�1 C l s::c g�S `� I� � �{ �QV z �c��c�c�i � Ic�c��-' � ��-�-o�� t,�� '� �i� �' � � �-� .k-��s c �r -f li �� .m�rn� � �h�� c G�. � � c�s �..��_��-� �S �`'��-� � p�1�� 'M�-� U.�` � ��" U� n eL. p�h ��.-t� �k� C� �n c�� >`� 1�� r o.� � r`�u-j �� .�� -�`-�-� a�� 1-�a..� e � Pcv��-«`�� -�-t c�c-e� cL�s m�s�� '�� Notice of Claim Form, City of Saint Paul,page two All Claims—ulease complete this section -- - Were there witnesses to the incident? Yes No �� Unkno (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 landmark, etc. Please be as detailed as possible. If helpful, attach a diagram. i� �'1� �� ' i � 0� L Q 1 � :�t_�n(`c�� Please indicate 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. _ - t, \ C C' _ � � Vehicle Claims—nlease complete this section ❑ check box if this section does not apply Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In_iurv Claims—please complete this section ❑ check box if this section does not apply How were you injured? 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 By signing this fonn,you are stating that al[information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a fa[se claim can result in prosecution. Print the Name of the Person who Completed this Form: �usjctl ,��;h.��:f Signature of Person Making the Claim: ��!��' Date form was completed �� Z I �� i L Revised April 2007 Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 98 FORD License#: 645BEA CN: 12238554 Invoice#: 140613 Date/Time Released: 10/08/2012 13:17 Tow Charge: $ 54.50 Released to: TOTO Storage Charge: $ 30.00 Paid by: CASH Admin Charge: $ 80.00 Released by: CHERI Tax: (7.625%) $ 10.26 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 174.76 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: $ 174.76 on this form prior to leaving the impound lot. Damage and/or other problem: Police Report made: Yes_No_ IF Yes, CN , If N0,Why? TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT 5/2000 Signature 3� 3� 3 �e 0�3oa m v � 3 « a;'o �� D tn ° � i z w i z :� n 0� m .°. m a x � � ' m s ID - m c� C m c 3 ° � � � � o � Z1J Z' p3C o3� A � � O T C 03 T\ 0 c c � n 3 o s O � 3 O < � -. Z O -� 3� 3� c K uoi� i 3 .L 2 " � 6 Z � o : sm ">� d a � 0 3 a - � 3 z 0 � s<o y A �� ._ � A ° Z m N n 7 �G y Of� ^� o c G p.=� � o � o� � D a� a '10o O D ami �eo ° A N a� O � O � � o T T� o � � o� p m n p � o r2 O n� o QJ � W 2 67 �l�� o� I�q 3 � CAfi ..�. p - � �C 0�fp . 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