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Her ��[VEt� FEB 1 5 2013 �i i Y �Lt�K NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 stntes that"...et�ery person...who claims ddmages from any municipality...shall cause to be presented to the ,governing body of the municipalitv within 180 days after the alleged loss or injur-v is discovered a notice stating the time,place,nnd circumstances thereof,and the amount of corrcpensation 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 KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name y'�� y'�� Middle Initial - Last Name ��-� Company or Business Name ��' _ Are You an Insurance Company? Yes/t� If Yes, Claim Number? Street Address � �� `��4e�wcG O' �f"- City st• �CtU � State /�1 i nn�.��u Zip Code h .�� Daytime Phone(�`�� )`��8-6�Cell Phone(�5� )u6�-��ZZ Evening Telephone(�)KGS- �122 Date of Accident/Injury or Date Discovered 1 Z I��t2 Time�am/pm Please state,in detail, what occurred(happened),and why you are submitting a claim. Please indicate why or how you fee the City of Saint Paul or its employees are involved and/or responsible for your damages. M� h;c�(� iN�S , s�l� t�,� 1-�ec,. 2� at m� wc�s-� Ga.ce wl,;le 7 w�zs �% � wcr � � � le.f' - e �l�ce �n�V id �1 e �� n.6 � n � �rr �ti- 3 w e�ks ! ly�.z_F �..e. - (� (�e� � r,.� -�C,[� r� � ; �;,o� is �n i -r�„� (� becr,u � � snc,�� .n�r >q � W�cs l,rz, �r' �'26�1.>c I �� --+ ; o � he,n � w�ish f �''y �',:.u�+ -}� � � ao we.�. �e e' S �ibw,cXcn�1' �ny c�.:r ��•� �� 7�f'� � �e I�I 5�'�Q.i!I �i� V�L�c'��1� MV V�-�iCIQ.. i 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 di 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 copies of all apulicable 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 WII.,L 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$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-please complete this section = Were there witnesses to the incident? Ye No Unknown (circle) Provide their n�me ,addresses and telepho numbers: - �� C.,i.�. o��5 P�r� �. �-i- � L�SI�-77�-�(�{$ Lc�n; 3��y, ��l Ar�n Were the police or law enforcement called? es No Unknown (circle) If yes, what department or agency? '��c� c��a�Y�r'��n�" Case#or report# l2- 2 d`l-36�1 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. M c:c� w�r-5 loc�t� �.+.e� �„re.� �n �5�1 li'C��SSS�F%C� �-c 83� ��iG' �{�,n,.e Roa�P_ Please indicate the amount you are seeking in compensation or what you would like th City to do to resolve this claim toyour��tisfaction. � wo'alr� � �� r� � m�rt� �a�. -k �� w{�- �c�, ��o �vt i rn t�.. (� � , i�- t,.�o,.(c� �rv�f l y hZ�� r+'t� w� /�'�� c-l�o l �r.�zn s� Vehicle Claims- lease com lete this section ❑check box if this section dces not a I Your Vehicle: Year �qas Make I�o a Model .f�c,c��-�;Q License Plate Number �KcC H� State��N Color ��+� RegisteredOwner �1�� lina N� Driver of Vehicle �lor�`l�r��l�Y Area Damaged - City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) � Area Damaged Iniurv Claims-please comulete this section �check box if this section does not applv 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 Complete 's Form: ° f' e� 1 � i Signature of Person Making the Claim: Revised February 201 I �ain� Paul Po�ice �mpound Lot, 830 8arge Channei Road, Vehicle Release �orm ;,�ake: 95 HONdA �ic�nse#: 640CHV GN: 12288937 3nvoice#: 1823b C�atetTime Released: 12/14I2012 20:27 Tow Charge: � 123.95 Released to: TOTO Starage Gharge: � 45.00 P�id by: CASN Admin Charge: � 80.fl0 Rele�sed by: PHENG T�x: {7.625%) � 15.55 I,tt�e undersigned,have recovered the vehicle described above. Subtotai: � 2�4.50 I trvill check the vehicie for damage or any ather problems that ��?�y have occt�rred while this vehicle was in the custody of the Service Charge: $ �.00 Saint Paul Palice Departrnent. I acknowledge l wiil report �amage andtor any a#her problems to the Impound Lot staff Total Chargss: $ 264.50 �n this farm prior to 1ea�ing the impound iot. Damage andfor other probiem:_ Poifce Repor#made: Yes_NoT EF Yes, CN , ff NO, Why? � ''`1 TC3 PROTECTrY U RIGNTS REPORT Y PROB�EMSlDAMAGE BEFCIRE LEAViNG THE Lt�T ;. � �.. � �-�,,,.,��-��--�~�� _ _ � �;`2�i00 Signafure _� � / � ; � _ <�,3 ��2L,l�s +,:t 1��"r`�t:5,� � �� r t �;� { ��, � °' " �� {��f'" _—__ __ .. _._. ----- . ___ ` �c��.�c:�: c�r:�7:��r�;��1�r c��r��1r�s_��;t��.��, ��, � � ,�. �-� t. . :��:,,.. � .r�,:i ,_. �� : .<r, ,.�,.. , . .� ._ . �� ` �+p� 't'�`$'�"'��,�.__ � . t .'�i;t`�i � .f�:1.t:: z.i!:=;�(:ti :!r.'E.��:i��: � ��. � ��i3af 1'�rul Y<Eliceltecu��€fc i!�kit ;i� 1� 2(zfi�5?4i(1 ! � , ,