Meden .� � ' � i . ���:
Ir�str�xct�o�s far Fili�c� iUatic� of Claim to City of Saint'Pau!" �� ;�
Minnesota State Statute 466.05 NOTICE OF CLAIM...(Elvery person..,who claims damages from any
municipality...shall cause to be presenred to the governing body of the municipality within 180 days after the �
alleged loss or injury is discove�ed a notice stating the time, place, and circumstances the�eof, and the amount of
compensation or other relief demanded
Please complete tl�is form in its entirety t� .�i��l���ting your answer to each question in
the space provided. If additional space is needed, please attach additional sheets.
APR �2 2013 �
PLEASE RETl�1R��t-�LER�'�9ffice of City Clerk
COMPLETED FORM TO: 1 _7_0_Ci�y_Hall __,_�
15 W ICellagg Blvd
St Paul MN 55102 ,
Your Name: �,
`,� C ._.. _ . _ .. ..... _... . _ ...... . . _ . _.._..
_ Street Adclress: ��i' _ fMl Yl_, �C1�(J _ . _ _
City: \(� V�J! , State: � Zip Code: ���
Daytime Telephone: �`�) �3 ` ����, Evening Telephone: �?�l b) ��j � � 6���
�
Date of Accident or Incident: � �Day of Weelc: (�S, � Time: am or pm (circle one)
l/✓GG�. i c. iSS� <�'. S�j �
�� � ��
P!ease �tate, in detail, �.ivf�at occurred and the circumstances surrounding the event. indicate how the
City of Saini Paul is involved, and why you feel the City is responsibl`e.
� c�-✓�c.�.cy. h,o C�U� A.� Cti �2w�.S �c��..5�. w e.�` �' WtSN
l S i �-�- �,.��. � p
e_un �-�.c�. i o t.••�rc�. ��. ,��.w�
7o•rc u�r c� . 1W4vun o�- ,�, ww� � ��.1.�, o �-' c�n. N••-•-. `
c,w w�.5 �a:..�e. - /
�ro �.. w�: o w i Ve�n..�, �
I
Please indicate your reason for completing this form:
C-1 Vefiicle accident �-7 Other property damage (please provide specifics below) ;;;,�j,�I
❑ Vehicle was towed `��
:.i':
H" Vehicle damaged wIM►4. �o�s� �l❑ Other injury to person (please provide specifics below) ,,'�,�;
.
❑ Slipped and fell on City property
';;''�
Please provide the names and telephone numbers of any City employees involved in this r s
incident/accident and how they were involved: ;
T v�.�� w �,.�L..c, �...`� v�.�.;C.�. �D� e�+e..S o t.�� v �
a
v. a w�-. � w�,l � a• �-;.c,��-
� c cl�,c.l�. ' r �
;
(over)
' ,
�
, "
If your vehicle was involved, please complete the foilowing:
Year, malce, and model: � License Plate Number.
Extent and area damaged:
Was a City vehicle involved in tl�is accident/incident? Yes No (circie one)
If yes, please complete the following: Type of vehicle
Year, make, and model
� Color of vehicle License Plate Number: -
Description of vehicle
Location of accident/inciclent (please provide specifics sucl� as street address, intersection, cross streets,
-
���`�r�i�, fiaciiitq nart�e; etc.�: --- - - - •:
_Please draw or attach a diagram if applicable:
Please specify the nature and extent of the compensation or other relief you are requesting. Please
attach copies ot any bills, receipts, ticl<ets, or other documents to support your claim. If you are
claiming damage to a vel�icle, please submit two estimates.
Were there witnesses to this accident/incident? Yes No (circle one)
If yes, please give the names, addresses, and telephone numbers of the witnesses:
Were the police called? Yes No (circle one) If yes, what department or agency? •
Police report number: -
Please print the name of the
person completing this form:
�
Please sign your name: ��
�.
Date form signed:
Risk Mgmt Division - Revised 1-30-01 � '!,!�'
,ti��,1r�
''�"�r���;�!�::
_,
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 91 HONDA License#: VPT350 CN: 13055633 Invoice#: 143576
Date/Time Released: 03/25/2013 10:15 Tow Charge: $ 54.50
Released to: TOT Storage Charge: $ 45.00
P ' by: CREDIT CARD Admin Charge: $ 80.00
, Released y: CHERI Tax: (7.625%) $ 10.26
I,the undersigned,have recovered the vehicie des�ribed above. Subtotal: $ 189.76
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the cust�dy of the �ee��t't�arg�:----�-- . -_�.�_ ,,.�;�
Saint Paul Police Department. I acknowledge i will report � �
damage and/or any other problems to the impound Lot staff Total Charges: $ 189.76
on this form prior to leaving the impoun I t.
Damage and/or other problem: �� , ��V �r y� \ \'� ��G���
�'C �`'� �YO�,y�
Police e ort made: Yes_No� IF Yes, CN , If NO, Why?
TO PROT T YOUR EPORT ANY P�OBLEMS/DAMAGE BEFORE LEAVING THE LOT
,,
Signature si2000
�
*�