Ali _ �,,. �����'`s'��
1��`����� �� ��,��1�� �'���� �o ��� ������� ���� �����, I�✓�ii������t�
�l-/i�v�esotr.St�te S1a�ute=F66.0�slates thnt " ...ei�e�y persa7...rvhe c/nin�s damao����c�ii�l�,s�s��crlri��...shn/!c�n���e to be presenred to Nie
goi�er•ning bocl>>o/�the nim�rciE�alih�ri�ithrn /80 dnys nfier Ilre nlleged/oss a�riyzri��rs rlis•coi�ered a rrotrce statirr�the tinze,pince, n��d
crrcunutnnces Ihereof, n�z�l the amou��l of com�ensation nr or6�er relref demni�ded."
Please comPlete tliis form iii its entirety by clearly ty�ing or priirting yoin•answer to each question. If more space is
needecl, att�cl� additional sheets. Ple�se note tli�t you rvill not be contacled by telephone to clarify ans�ve►•s,so pi•ovide as
mt�ch information as necess�ry to explain your claim, and the amoi�nt of com��ensation being reqiiested. You ���ill recei��e a
r��ritten acl:no�vledgement once your form is received. The pi•ocess can talce uP to ten weel:s or longer depending on the
nature of your claim. This form must be signed,and botl� pabes completecl. If something does not�pply,write `N/A'.
S�1>1� C�MI����'�D ?��flI�M �� OT��I� DO�TJII��NTS 'T�: �i'I'Y C1,�R��,
15 W�S�' I���,LO�� BLV�, 310 �IT'Sl �IAL1L, SAINT Pr�fJL, 1V�N 55102
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F'irst Name �i ,�t' �.Q N(iddle Initial�Last Name ���� _-
Company or Business Name
Are l�ou an Insurance Company? Yes/�o If Yes, Claim Number?
Street Address ��Z � L���� (�.� _ �
Cit �-Y i � I Q � �r State � Zip Code_��
Y
Daytime Phone (�_�����ell Phone ( ) - �vening Telepllone(_) -
Date of Accident/ Injury or Date Discovered _���� "L Time ►�L�v�am/pm
Please s+_ate, in detail, what eccurred (ha��pened), nnc' w'1y you are submitting a claim. Please indicate why or ho�i�you
fee( the City of Saint Paul or its employees are in�✓olved and/or responsible for your dama�es.
�
C3
_ � � e ^�._2 't'r,�b �; �T�.��nP �,9�!L i �—
iV' �
Please checl:tlle bo�(es)that most closely represent the reason for completing tliis form:
❑ Nty vellicle was damaged iil an accident ❑ My vehicle was damaged during a to�v
❑ NIy vehicle was damagecl by a pothole or condition of the street ❑ NIy vehicle was damaged by a plow
❑ NIy vehicle was wrongfiilly towed and/or ticl:eted ❑ [ was injured on City property .,�" ..�
Q�Other h'Pe of property damage—please specify .j_)�L(P r,��Lti��--��,'��Y1;� � a�..,, l)ti v/ '�� !"`C �Dl ,
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all anPlical�le documents.
Por the claims types listed belo�v, please be sure to include tlle documents inc(icated or it will delay tlle llandling of
your claim. Documents WILL NOT be returned and bec;ome the property of the City. 1'ou are encouraged to l:eep a
copy for yourself before submitting your claim form.
O Pcoperty damaje claims to a vehicle: two estimates for the repairs to yotn�vehicle if the damage e�ceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies oCany ticl:et issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates iFthe damage eaceeds $500.00; oc tlle actual bills
and/or receipts for the repairs; detailec( list of damaged items
O Injury claims: medica( bills, receipts
O Photographs are ai�vays �-velcome to document and support your claim but will not be returned.
� Page 1 of 3—Please co3nplete a��d retia�-n �oth ��ages o�f Claim Form �
. . , �y �� � l� �L�� `V� v
Y'�i1��3-e to con�plete ar�r] i-e#nrn botii �;��es��vill i-es�ilt i:i dela��in #3�� 3�zndling of yoin-claim.
�11 Claims—��lease com��ie#e i�3�is section
� Were there�-vitnesses to the incident? Yes No Unl:nown (circle)
Prov de tlleir ilames, addi�esses ancl telepllone numbers:�Cp,{�� �,v l,�G ,rYl � Ej
„
� I��`�i ID � �����
Were the police or la�v enforcement called? Yes No'� UnIC110\Vll (circle)
If yes; ti-vhat department or a�ency? Case# or 1-eport#
Whece did tl�e accident or injuiy tal:e place? Provide street address, cross street, intersection, name of parl:or facility, _ . __
closes�laurl��.ark, etc. Please-�e as clet3iled as po�si�f�. If necess�ry, attach a diagram.j� �� ��,-��t,,q (��,�,,Z,r �
_j�� � �'fi +�'�v i � � 5�ylv�
Please indicate the amount you are seel:ing in compensation or what}�ou would lil:e the City to do to resolve this c(aim
to your sat;sfacrion.'T� r,.�vvl r ; k.� `��--L,�`/ Tp �(��r^—�X � �c,�.t �• 5-� ���
�j�6/—� c�� � � r
Veliicle Claims—nlease complete this section ❑ checl:box if this section does not a��lv
Your Vehicle: Year � � Mal:e y Model C �,��rf
License Plate Number ''�� Sta;e .^�n Color vY��P
Registered Owner
Driver of Vehicle ������} � �
Are� Damaged ��CK ,l,v 3Y� �Q Y
City Vehicle: Year Mal:e Model
License Plate Number St�te Color
Driver of Vehicle (City Cmp(oyee's Name)
Area Dc�n�abed
Iiijury Claims—nlease complete this section �ieck bo�if this section does not a�ly
I Io`-v were you injured?
What part(s) of your body were injured?
Have you sought medical ti-eatment? Yes No Planning to Seek Ti-eatment(circle)
When did you receive treatmeni? (provide date(s))
Name of Nledical Provider(s):
Address Te(ephone
Did you miss worl:as a result of your injuiy? Yes No
When did you miss worl:? (provide date(s))
Name of your Employer:
Address Telephone
❑ Checic here if yoii ai•e attacliinb mo►-e pages to this claim form. Nurnber of additional pabes
B.J1 Slg'i1112o tI1IS fOYYi1�)�OLi C[i"2 StClllila tIl!!1 lIII 1/I�OYY/1Qt1014)�Ofl Il(IV2�1YOVllI2ll IS tY[l2 lTl1lC COYYBCt t0 tIlB IJBSt
ofyorn•I�rzoivlerl�e. Unsi,;�7ed forms �vill�TOt be p�•ocessed.
Sllb1'111tf1i1b a false claim can result in prosecrrtiou. Date forn�was completed ��_ 2,� — � Z
S
Print the Name of the Person rvho Completed this Form: !�v S� {% � � )
Sibnature of Persopi NIalci�ig tlie Claim: �;�,� ����� 'Q i�--'"s-l� �
Revised 1=ebruary 201 1
Saint Paul Police Impound =�--_�.� �, Vehicle Release Form
Make: 07 DODGE 656 Invoice#: 141383
CIT`/ OF ST. PAUL
Date/Time Released: 11/19/201 SPPD I�4POUND LOT w Charge: $ 54.50
' 830 BARGF CHANNEL ROAD
ST. PAUL, MN 55107
Released to:T-O�� (651) 266-5642 �rage Charge: $ 15.00
DATE 11/19/2012 MON TIME 14:06
Paid by: CASH Imin Charge: $ 80.00
A TOW T1 54.50
Released by: CHERI ADMIN FEE T1 80.00 ix: (7.63%) $ 10.26
DAILY STORAGE 15.U0
I,the undersigned,have recovere TOTAL 159.76 �btotal: $ 159.76
I uvi+F check the vehicle for dama CASH 2O0.00
may have occurred while this ve CHANGE �4�'�° 40.24 ;rvice Charge: $ 0.00
Saint Paul Police Department. I SHANNON A 006582 OU000 � ��^`
damage and/or any other proble _ ... ..... . ..: . ..... ..... ..... �tal Charges: �$ 159.76
on this form prior to leaving the impound lot. ,
����__�
Damage and/or other problem: `�i � I�� GC Y�'�/.I„ I� ��-�
��.�2�n �.
.
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS R PORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature r �' � si2000
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