Jacobson NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that °...every person...who claims damages from any municipality...sha[l cause to be presented to the
governing body of the municipality 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 KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
/� --�
First Name K� ��L<<� Middle Initial Last Name � C . ���1'l
Company or Business Name � ��
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address � �l���(� �,�J�1 P��c`i �� L��l �,� � �
City �'�-- t�G(,A_�i�_� State �� Zip Code� �
.�y � �,
Daytime Phone( ���Cell Phone(�� �&� � �vening Telephone( ) � - a/�
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te of Accident/Inju or Da e Discovered � � �0/ Time ���� m��
�i� S��'1�l.t3 p� � O � °Z ��� ��•v V�1'� `
ease state, m detail,t�vhat occurred(happened), w�y you a� s�it�3��j�"�'�!I�4f�h�lease indicate why or how you
feel the City of Saint Paul or its employees e ' volve�l and/or spo sible for your damages.
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Please c�eck t�ie box(es)that most closely represent the,reason for completm�s fo �s> _1-. �'1ct�� �
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❑ My vehicle was damaged in an accident ❑ My vehic e was damaged dunng a tow �
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow � �U
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�My vehicle was wrongfully towed and/or ticketed ! ❑ I was injured on City property ���� �
❑ Other type of property damage—please specify �„��� C� �
❑ Other type of injury—please specify
J► W�-`��Q
In order to process your claim you need to include copies of all anplicable documents.
For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of �,itvL
your claim. Documents WILL NOT be returned and be�ome the property of the City. You are encouraged to keep a �
copy for yourself before submitting your claim form.
O PropeRy damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceed�� �
$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 U fZ,V� .
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 ��t Sb t:�
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 h`�t�S�S c��
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—ulease comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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,
close�landm k, �c. Please be a d ailed as.po�ible. If necessary, attach a d' gram.
�
Please indicate the amou t you a�e seeking i�co pensation or what yo wo ld like the City to�do to resolve�his claim
to our satisfaction /
.
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Vehicle Claims— lease com ete this section ❑ check box if this section does not a 1
Your Vehicle: Year a�0 i Make Model �Of
License Plate Number �' 2State��( Color -
Registered Owner r c�. - c� �
Driver of Vehicle
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 `6Q check 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 tu this claim fr,rm. ilumbec•of additional page 3
By signing this form,you are stating that all inforntation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be prbcessed. .
Submitting a false claim can result in prosecution. Date form was completed
�3 �' /3
Print the Name of the Person who Completed, ' orm:
/�e hec���, J��bs�r1
Signature of Person Malcing the Claim: � l� �r
Revised Febru:►ry 2011
Sair�t Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 01 TOYOTA License#: 797BAZ CN: 13036203 Invoice#:20341
Date/Time Released:02/24/2013 09:03 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 15.00
Paid hy: CREDIT CARD Admin Charge: $ 80.00 �
Released by: MAI DER Tax: (7.625%) $ 15.55 � \ ,�
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I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50 �
I wiil 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: $ 234.50
on this form prior to leaving the impound lot.
- ...;-_._-Damage andlor other problem: - - ___ --��°= _
Police Report made:Yes_No_I�Yes, CN , If NO,Why?
TO PROTECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000
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