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NQTIC� OF CLA� �QR11� to the City of S�int �aul, Mina�sota
Minrzeso�r�C1arr..Sraru�e 46G.Os,rfnte,s xh�t��.,,C�'Fr}°(ler,SOn...WhO iIQ1TrRS(�RrrL�gES,{r�rtt Clf21'lT41417tCR�R�i1,y�...,nc�tlt ccuese to be�rre�senrerl fu tlic
xoi�crning Hndy?f'rhe iuunici,f,alitp w�ith.in 18f)�7ays afrer rhe adlegNd fos�s nr injurv i,s diec•nv�red u�nottce statin�tAcr timc,pl�]Ce;ars�
c�r•cu�r�,srance,�•rkercr.;f,ant�Jhe ar+tt+unt nf cnmperualinn nr ar.her•relic{dermnrrderl,"
Ple�tse Comip�ete thi5 for[n in its eelHrety by cleurly t,ypiltg Or prit�ting vnur�tLSWeK tn eacl�que.stiott. IF nn�are,pace is
n�ded,a�ttuch adclitional slteets. .PICASC npte t11at yA11 SYIII p�f 1�C cn�nta�Ed bV f�i�phOq.f tn c1n.l3Fy AIA.GR'�a'S,�c►provide as
�R1.CIt 111P(1CRlAti(IR b5 R6(�yAC}'tb Ca[7IAIR j'Alii'CIRAt'ii�llAk[I tF1E'9117ilLIllt AF f'OI[1pfa1S14tIp17�l[l�k'LQII��• �Fnu will C?Cf�VC R
written ecknowled�exnenf o�rr.�ynur focm is re.ce#v�d, Tl�e Qroce,�c.�n talse up to ten w•eeic�or lon�er depending on the
nature of youz claim. ThiR form nrtust be sl�nctl.and hnth pa�es co!mp[cted. If socneEl+ing dceR not apply,writc`N/A'.
SEND GOMPLETED FQR�V[ .AND QT�k��t I'�QCUMEN'�'S TU: CI'TX C�ERk,
l.� WFST KELL�GG BLVD,310 C�'�'� H��LL, SA�.��TT PACT.L� MN 55142
� 1 J� � �� >
T�irst Natt�e ;_U�'t l v Middle initi�l M_Last Name_ ( G i. � [
Cocnpany or Business Name ,/��� —
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Arc You nue Insur�n.ce Company'? Yes7� ,i,f Yes,Clain�Nusx�E�er?�,� ,�,—
St.re.et Address ,��� �t/i G�O Tl � � .� _ .�,.�..�
c�cy s• _�/ z��c�a� ��.J�
L�aytime Ph��1e(� e- �a� Cell Phone{ � � Bvenitig Telephc�nq
%
Uace of Acciaend Injury or Taate Disc��vEred�, Ti.me. � �em��rrt
Pleaw st�ee,i�!d::tail, what occa�red (h.t{tpened:,and why yc�u�re cubmittin�a clairt�.Please indicate why or how yo«
fe�l thr Ciry of Sti�nt k'aui c�r its employees ar.e ir�vc,i�.:.�a�;uJ-:r�per,crosibte foA•,yoar dama�es. .,,.,...�
�.,.. -,.�..,-- �
Please chec e�xles)that m�st closely represenl Ghe reasor�far iompiuting this fortn:
❑ My icic�waa damaged in a�� acczdent L'7 My vehicle�vas d�ma�ed during a tow
❑ vehicle wss dam�,ged hy a�othole vx C�rlditio�i of tl�e strect C] My vchicle was dz�maged by a pl�w
y vehicie a��.s wro�igf�illy tawed andlor ticke�ec� � I was inj❑red on City praperty
CI Ot.lter. ty�e.of�i•�perty d.xnzage.-pleace specify�_Y...._...Y..,�...�-.�.�.-_ .__._�
�Other. type of injury-pl.ease specify,
Ia order to pru�.ess your claim vo�.,� need t�i�c�ud�conies�f all anniicable dacuments.
For. th�:cl�.ims types listed helow,ple��,s�be,ure to�nclude the documents indicated c�r it will delay khe handling of
yaac cl�im. :bocutnents WJLL L�IOT be e�twrcd and becornc the property oti tlt�City, Xou are encauragecl t'o:keeP�
cv�y for gnurseif befnre snbntitting y�ur eiaim forni.
O Pr.operty dama��:claims to a vehicEe; two estimates for the r,epa.irs to yonr vehicle if the damage exceeds
�(}p.{j�}; dr ehe actual,biils and/o.r receipts for tl;:.�-epai.rs
Towing cl�ims: Iegible c��7ies of any tick�[isstced.and s cupy oF the irrtpound l�t rcceipt
Q C?�Fser proj7e�i,y d�.rr►1�c elain�s:two repair�stimatx.s if the damage zxcsects$5013,!}();�r. �.he actual hiils
ancL'or recci�c.� for CEte repairs;dcxaited I+sc of dant��;�d icerns
4 In,jury claims:medicll bills.i'�CC1��S
C7 Phoco�r�ahc�u�e atwaya W��:Ico�.ue t��loa.��ttent:�ncl 4u�iport ya�ar.clairn hut will ttot be.recurned.
pR��1 q#'2�-P1ea�e�mplete a�d returre bat.� pages cf Claim F'orni
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12/1012012 14:32 7154250666 UWRF INFODESK PAGE 01,
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�'aih►re to com�lete and relu�n.both pages will result in delav in the handling o�yaur clairn.
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All Cla�ms—olease<omolet�this sestian , �;
Were thzre wit�esses tc7 the incident? Ycs Ns� .'�U i (eu�cle) ,
Provide thEir n�une;, addcesses��nd tele�la.onc nunzb�r � �� -�—�-- I,
Were.the}�olice nr iaw e�►�forceiuent callea? Yes Nu�. Linknown {circle)
Lf yes,what dcpartment or lgency? �ase#or reFoft#
WEzere clid the accidert or injury tflke�tace? }'rovi.de street address,cross strcet, interse,ction,namc of Qark ar facility.
closest landinark,et�. Plcase E3e as det�.ilcd as�ssible. If necessa�y,attt�ch a diagr:uti.
P(ease indicac�che amouc yvu are, eki *zn euinpe.nsation or wh�t,you woulef li.ke t[ze City t�do to resulve this claim
tc�y��ar s��.tisfacti�,m.�.�.�.� -�---��— -
— a4e co�n lete thrs secti n �� � k bo if tliis ection does at a .
v�t���ctA��m� tG
Youc Vehicle: Yuu•,,,�,1)-�-`o�.—A4ak.e�.,._ -- Mcxted � �
License�late Namber St,�te�.�lor���.e°.�--^
Re�istered.<?wner. C � �S � �� �� �
briver of Vehicic_,��_ ��,.., �`.�:- - "'�' �
Arza I)amagec� ,..�...��.Lll�,r '
Ciry Vehicle: Year i�'Cake M�3c{El
Licen..se Plate Nunxt►er Staee __C��lor
T)river af'V�hicic(City Employce's�3ame)
;��ea rJaa?a�ed� -
I 'u Claims— 1 com lete this sectioo —.--
che.ck box if this s ction d es n a 1
How were you injured'? —�` ^� '
,� �
What pact(s)of your body were in.jured? - "�"""�' �
Have y��u sougl�t medical traatment? Xes No Pla��ni��g to Seek Tr�acment(ci.rcle) ,
(prc�vide date(s)}
Wheij did you re.ceive treatment' ---- — —
Name.ot 1V[edical Pro�icicx(s}; Telcpl�one
Add.ress -�— �� i
Dici yaL�miss wc�rk as a resalt nf your inji�ry? �'e4 ��vide datels)) �
lP i
Wia.en did you mi5s wark?
Name of your Einpioyer:,.�. '�� Telephonc
Acldcess_. .�.�--�--�—�---°
❑ Check here if.ynu a�e attAC,hing mnre�ages tU thi.c c.laimi foren• Number, of addttional pages�
tiri tlaaf a�l ar� orrna�liare ynu have provided is trr�e a►�d correci ta the best
' in thr,s orm, vou�cre sr.� � f
�3v ssg+� � .f
o.�'your knoH�Iedge. Ur:Slg�cB(�f�r�1S W[II r�Ot I�P j)r�)CCS,cef�.
) // /�
Submit.ting a fa�ce claim cnn resutt in prosecution. Date farm waq comP�ete� °�'
P�int t.�fe NAme of khe Ferson�sho Compteted this F«t�m:
L' ,s � -%�- � �
Si�natac�e of�'ec'son Making Che Claiixx: ---- ,
Revived Fehruiu'y.01 1
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sr �RU� inPwr��or
830 BARGE CHHNNEL PD
SAINT PAIA, MN. 55797 '�50
651-266-564�
Herchant ID: 80063if01y,
Ter� ID: 00173400088�1063ts�_a4:•.
Sale
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VISA Entrv Method: S�i�ed
Total, f 212,50
12i10i12 10.02:5fi
� Inu a; 0�1� APpr Code; 02�i�3 � �
- Rparud; Online -
Customer Coav
THANK 40U!
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Saint Paul Police Impound Lot, 830 Barge Channei Road, Vehicle Release Form �
Make: 02 CHYSLER License#: 978DYC CN: 12288997 Invoice#: 17519
Date/Time Released: 12/10/2012 10:01 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD � Admin Charge: $ 80.00
,�
Released by: RITA 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 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: $ 219.50
on this form �irior toJeaving 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
_ Signature _ si2000
_ _..._._ ,� I
� 5t. Paul Police Departrr�ent for '
, ,
_. Ramsey District Court '
RECEIPT '!
� ;
' Date/Time: 12/10/2012 10:01 Invoice #: 17519
Vehicle Plate: 978DYC/MN
Payor: OWNER Location Paid: Impound 5now Lot �
Citation: Amount:
' 888751133 $ 53.00
Total Amount Paid: $ 53.00
Paid by: CREDIT CARD