Winner Microsoft Word-Claim form 2.11.doc- 15774 �E�'���w.stpaul.gov/DocumentCenter/Home/View/15774
MAR 0 5 2G��
NtYTI�� tJF CLAIM FQRM to �he C����.t Paul, Minnesata
�firaraescrra Smte 5n�rute�b6 i}5 s�ars thnt "...even�prrsora...sa•f�n c(czirns daririges(rarn anti�muaicrpa(ir}�...sha(f cause ro be prtser.red rn rlie
gnrernirag bod p ojrhe rnuniei�xtlrty tvrthir 18Q days a�ter tfie c�/leged lnss or injury r`s cdtsenvered a raorrce stating tfie time,ptnce,and
eircutxstan.ses ttaerenf,anct the cr�naunt ojcornpensntion or ntJter re(ief clernandrd."
Please cexnplete this faern in its etttirety by�cle�ri,r-typing car printin�yrxie sanswer t�r each yuestIc�n. I�rnc�re�paee is
❑ecilcxl,�Yttach ackiitirm�l sficet�. Plu�se nc�te tht�t�csu will not be cc�nt�ctezi by telephcxie#ci clarify s�ns�vers,sca prc.f��dc as
rnuch irtforrnatic�n as nc�ess�ry ta e�lairt your ct�im,s�nd the amaunt of cocnpens�tion bring reques[e�. You witl rc�c�ei��e�
wcitten ackno�ledgerncnt cx�tce your form is t�eceivecL The process can kake s�p to ten weeks or lon�;er c�pending on the
n�ture of��our clz�im. This forrn must be signeif,and both pages caupletc�. If sornethin�cbe�not applti,write'N!A'.
SEND CtJMPLETED Ft}RM AND a►THER DOCUII�IENTS TO: CITY CLERK,
�5 WEST KELLOGG BLVD, 310 �ITY HALL,SAINT PAUL, N1N �5102
F�'rr�L N�ine�O�i�lC.'�� 'U Middle:(nitial � La� Ii1G�nx: w�NNp,(Z
�ampr�ny c�r �3usine�:s N<�n3e
r'1re Yau��n Insur�mce Gc��j��any`1 Yes! o It l�e�;,Claim Number`?
Street Addre�s 3S 5 ��-�'�-S /���
Cic�= �c�.i rvt �c,�-1 St�cz M t� zip�`ode s�I C�Cv
f)ayCiine Phcan�t i - Cell Phc�n<(40(0)546-(ooq� Fvc��in�Te1�:E}hUne��) -
I�ate of Acei�lint! Injur}• c�rDate;I)i�:�vei�;c� I Timc:� � � � �im/��rn
{?ler�se SC��te,in detail,v�-}�ai acc�arreci fhcrpp�nr,c3}, �tiad��hy yc�u are�u�r�t�ittir�� a cla'rm. Ple�►�e intii��te why or how�yatz
teel the CitV ot Saint Pa�al c�r i��n�plo}rees r�re in��ol��eei andlo�-res onsible f�or your damages.
_ � pa,rz-KQ.� o t� =K,�� s�t P l o � s;d� o� d t o�cs i
vJln.o�.� Z S�� l��v�,S �'� t� 5c�u1�-t ��.t,.0 2uLi�- TI�.�.� io4� �e. i�r
� �w �ed � c.cx�z- �o � atLv�.R- s�de.. 6F 1t� sfir�.�� wou�n�-f� be +oWe.c� -
o V Q d / ��i c1 ti t ��¢.. � �-i LK.�t oN dit�ta L�t-t2 r�%E' �-
�-i�„ . T o wtZs ia�e..R� b�n���ue�, pAre� -h.w i�-
Qt�- �- Si'd2 O {'�n.2 S�'RkD._'� - _'.� iVO'� c�.i'S� �i �
Gi 1-��i �� jv�St--�1ntl.. vvi i r�.Qowi��1 �c.R-5_
PleaSe check the hc�x{esJ that i�x�st closely'repre�;ent e re��san for�:ompletin�this form:
� My� ti�ehicle w��.� d�t�l�a�ed in an�fccident i �14Iv vehicle w�4 darnaged durin�a tow
� N'Iv vehicle�Fas dama�ed bv ��pothole or cnnditic�n of the street � Niy �3ehicle w�►s dan�a�ed L�y �plc�w
�Ilrty�ehicle w�i5��rongt'ully tow�e�and/�r ticketed � I u�-�a injured c�n Git}�pcnper€Sx
�C1the:r type �f pmp�rty�:ama�e-ple�r:;e sp�cify` —
�CJther type of injc�ry-please specify
in c�rder to proce�s your c���im voa nEt�d�tr�include copics ��C aII applic�able documents.
Far tt�e claims types llsted t�elow, please be�uxe to inc I de the dc�cutiients ir�dic:3ted crr it will dela}'the tiandling c�f
c
yc�ear clai�i, llaeumentS.V�ILL NOT be ret�irned and l� conte the prc�p�:rty'�Y the City. �'c�u are encau:ra�ed to ke�:p�i
copy for}o�rself��fbre���bmitti a�y our cl�rn fortn.
O Froperty dan�a�e claisns to rY vehicle:two es�ilnntes far the repairs to yauc vehicle if the damage exce�d�
$�OO.QO; orthe actu�l bi'(�Is�ndfor re�eipts for the r�pairs
�Towi►�g claitns: Eegib[e copi�s of an��kicket is��zd and a copy of Ct�e im c�und lot receipf
O(7ther property danjs►�e r:lainls t�i�t�pair c,�;[imates if the dama�e ixcee�ds, .00.�0,c�r the uc:cual t�i11s
r�nd1<�r re�.cipts i�c�r the rcp.iir�;;aet4iilcd list z3i��fanitrged items
U [njury cluims: me�icr� h�rr�, rzceipts
O Ph�tUgr�iphs�u�;alway5 welcome ta docu»�ent and�pport p�rst��•claim but will not l�e ietti�ro�:d.
Page I of 2-Please complete and return both p�ges af Clairn Fot-m
1 of 2 2/26/2013 11:22 AM
Microsoft Word-Claim form 2.11.doc- 15774 http://www.stpaul.gov/DocumentCenter/Home�ew/15774
Failure to complete and return both pa�es will result in dela��in the handling of vour claim.
All Claims—ple�s+�camplete this s+eetion
1�4FZer�there w�itnessea to the�ncident`? � Ne� Unkn��°n (eircle�
Pro�fide their names,addr�s�s�nd tel�phone neir�er�: �i'i-�l �ic�i�� e�u-D�O�S� �rsw I�?
_ -� �-�
Vl��re th�pr>li�e c�r law�:nf�t�rce:r�nt calleci? Yes c� U►Yknc�v�n {cir�:le:)
[t�yes,«hat dep�rtme►�t or�ency`? C'�a.�;e���r r�p�r�#
1�+t�eee dicl th� accid�:nE c�r injury t�r3:c placc:'? Prc���ide��treE;t addre�s.�.rc�ss �;treet,inter,;ectic7n,name ot parR or f.�cility,
clo�st l��ndmark,�tc. Please b�as ciek�iil�d as�ossib}e. If ne�es4ary> �tta�h a dia�ram.
�� ��.1-�S �J l;'� �LK� U� l Iv 2.St' Si�� O�s�(�SLt� i�-� � E S'� 5�2
, c5 S��
�Pl�as�indi�ate the �r�unt you are se�kin in�ompeflsat�on�r what yoG� u�oe�[d'[ike th��ity to do to r�solv�this c airr�
tc�yc�ur s�iTis�action. � �.� s 5�
�Fehide Clalms— lease com lete this section �check bax if thi�sectian does not s� l
Yaur Vehi�le: �i'eAr �OO\ M�ke �o a- �M�del C-c-o2-d
License Plate Numb�r MT_ �G t� St�rte I�IT CQlor ��1 VC2
R��;istere-d C?wt�ee �NY.. �'��v N2SZ
.
Driver c�f Vehicle �' i �N � �
Are�Damae�d � S i�i S
�ity t+'ehicle: Yc�ir Make c� cl.
I�icen�;e I'I�te Nuinber State Czslor
Drivci•or l�c�hicle(Cit��Emplc7y�.�,"s N�ti�e)
Ar�:a L�amaged.
Ln1�'�Claims—piease complete this sectlon �ch�c:k bc�x if this st�tivn does not apt�ly
Hc�w were you injured?
«hat part�s) of your bod�,� were injured?
H�ve you sou�;ht n�e;dicr�I treat�i�e:nt? Ye; Nca I'l:u�nit�s�t�� Scek Trtatment {c'r�:f�)
V4'hen did yc�u rcc�:iv�t��.atm�nt`? {prc���icle d�►te(s),)
Name ofi Medical Prn�ide�'{�*j: _
Address Tetephone_
Did you rniss work a�a�result of your injury? � Yes Af p
VVhen did Vou rnis�wark`? (prc�vide datel s))
l�Ia�i�of�rotar�mplo��er:_ _
Addr�ess Teteghane
p Check herc if�ou are attachin�mare pa� t�►this clalm fnrm. P�Tum�rer of additlonad pa�es
By signdng this form, yau are stating that alt in fo�ination you have �rc�vided is true ar�d correct tn tlae �iest
c�f yo�r knowledge. tl�tsigraed fornas x�ill not be processed.
Subrtar"ttireg a false clairtt can result in prasecution, Date form was campleted
Print the Name of the Persbn who Campletecl this Farm:
:�i�naturE.�of Person hiaking the Clalm:
ttiviscci Eehiu:u�y 2i)l l
2 of 2 2/26/2013 11:22 AM
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 99 fiONDA Lieense#: 4C130SG CN: 13036203 Invoice#: 19642
DatelTime Released: 02/23/2013 14:54 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ O.OG
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: ELISE 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 probtems that
rnay have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge� will report
damage and/or any other problems to the Impbund 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, CN , If NO,Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
S�gnature 5i2000
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