Loading...
Gordon �id�:����f'��, pEC �� � 2012 NOTICE OF CLAIM FORM to the City of S���Pat�����Vlinnesota Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...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 demancled." 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 will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and both pages completed. If something dces 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 ��Qi�' (i✓�� Middle Initial�Last Name (�✓��(J ✓1 Company or Business Name Are You an Insurance Company? Yes/No If Yes, Claim Number? Street Address �,��� �--��� V�. �. '�� City /�/�;nn e� b 6�l t� State�JI� Zip Code S_��ll jp Daytime Phone(�)�-�Cell Phone(�)�S-�Evening Telephone(���_ Date of AccidenU Injury or Date Discovered ��— �d '"��— Time �0:3 L �ir�i/pm Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees Aare involved and/or responsible for your damages. In/1�C '�-dvt� �%�Cr�,(�(� N V�t. ��.�tw-tt.-, (��d u� b..C-�ti ���-f tt_��P r- �►. / � � {✓�✓ ` � � ` � v � � (�� _' � �S , \ v� /l Please check the box(es)that most closely represent the reason for completing this form: ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow ❑lyly vehicle was damaged by a pothole or condition of the street �My vehicle was damaged by a plow ��My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim vou need to include couies of all applicable documents. For the claims types listed below,please be sure to include the documents indicated 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 keep a copy for yourself before 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 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 will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comnlete this section Were there witnesses to the incident? Yes No Unkn wn (circle) Provide their names,addresses and telephone numbers: r '�.� "7 � 1 Were the police or law enforcement called? Yes � 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, cl sest landmark,etc. Please be as detailed as possible. ff necessary, attach a iagram. .� � �� � ,� � . Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �.� . 5� i S�.e rd�a �,l�l Vehicle Claims—ulease comnlete this section �T check box if this section dces not annlv Your Vehicle: Yeaz Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Yeaz Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims nlease complete this section �heck box if this section does not apvlv 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 form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed ��. �' � �� �� Print the Name of the Person who Completed Form: z��r��2..0 f�'^ Signature of Person Making the Claim: Revised February 2011 � �� ��8 ��� ��fi � _ ' Citation# , • , ST. PAUL STATE OF MINNESOTA-RAMSEY DISTRICT COURT I III` ' in dul sworn u on his/her oath de oses and sa s: 'I IIIII)(II�I IIII)IIII)IIIII III�I IIII)IIIII IIIII III The undersigned,be g y , p p y * 8 8 8 7 4 8 5 8 6 * Date of Offense / � Time of Offense �� ' + Plate Veh.License No. Year! State ' Make Style Color ' Location of Offense: VIOLATION: SNOW EMERGENCY St. Paul Ordihance 161.03 FINE �53.�� � (Amount includes mandatory state surcharges of$13.00) CN � Citing Officer Citing Officer Number Dept. ❑Pbsted Night Plow ❑Day Plow ❑Plowed in(Windrow) ❑Tagged Before Plow ❑DroveAff , OFFICER'S NOTES � ❑NO PLATE VIN: Citation can be paid at the Impound Lot.Please read the back of the citation for payment instructions. CITATION Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 79 OLDSMOBILE License #: SEH�10 CN: 12288997 Invoice #: 17882 Date/Time Released: 12/12/2012 19:10 To�v Charge: $ 123.95 Released to: TOTO Storage Charge: $ 30.00 Paid by: CREDIT CARD � / �/ Admin Charge: $ 80.00 Releas�d by: LA�RY Tax: (7.625%) $ 15.55 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 249.50 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: $ 249.50 on this form prior to leaving the impound lot. Damage and/or other problem: ___. Police Report m�de: Yes_No_ !F Yes, CN , If NQ, Why? TO PR�TE�T Y!�UR RIGHTS. REPORT ANY PRn3l.EMS/DAM�GE BEFORE LEAVING THE LOT Signature --- -- ---- 5/2000 -____ . _. _ . _ ,.. ---- _� ___ - � ,.,.�- .