Untitled (5) ����:���� '
DEC 2 U 2012
NOTICE OF CLAIM FORM to the City of Saint Paul��i���a
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 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 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 does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KEL OGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ,��`�`�+. �� Middle Initial4� Last Name V�/��� (W�!
Company or Business Name �
Are You an Insurance Company? Yes/�If Yes, Claim Number?
Street Address � �S� � ��� � �
City G�1/�.'� ��� State �� Zip Code ���
Daytime Phone(�)�Ti�Cell Phone(�) ��- �yL Evening Telephone(�)�v�v- Z� �
Date of Accident/Injury or Date Discovered �- /a Z Time am 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 employe s are involved an o-resp nsible far your damages.
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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
❑ My 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 j��:: nppd to include copies 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/ar receipts for the repairs
}BCTowing 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/ar 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 complete this section
Were there witnesses to the incident? es No U�own (circle) �" z -�
Provide their names, addresses and telephon umbers: n ptvi G�. �U e L.1�r �S� �U/ ��
�
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,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. Z�a , �
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year�_Make Model
License Plate Number h State Col r
Registered Owner � iti�r .� 1 R� ��`!��
Driver of Vehicle r---�
Area Damaged ��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section J�'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 form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned fornzs will not be processed.
Submitting a false claim can result in prosecution. Date form was completed � Z
Print the Name of the Person who Completed this F � ����-� v" � � � �,�� �
Signature of Person Making the Claim:
Revised February 2011
Saint Paui Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 03 HONDA License#: 5546YR CN: 12288997 Invoice#: 17848
DatelTime Released: 1 2/1 0/201 2 08:51 Tow Charge: $ 123.95
Released to: TOTO Stora e Char e: 0.00 ��
9 9 $
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: TABITHA Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
I will check the vehicle for damage or any other problems that
may have occurred v�:hile 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: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_ IF Yes, C!V , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000