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Thurmond (2) RECEIVED APR 0 5 2013 3 � 1 � I l� This claim form is being returned without having been set u�a��f��following reas�ns: Failure to provide a written description as to what happened and why a claim form was being submitted (page one). (�--Failure to provide the proper and required documentation (page one). �� Failure to provide a date of accident or injury(page one). Failure to indicate the amount of compensation being sought (page two). - p�--Failure to provide information about the vehicle involved (page two). -- �Q�� Failure to r�rovide information aboilt tne iniur��claimed (page tvaol. � lX Failure to sign the claim form (page two).�-��v�-e- �Failure to print the name of the person who completed the claim form (page two). --�Or�2 �ther: �G ` � (��2., `�� ` �`�x-�"� �Ot..��-l.t�.Q, '�"� �, _" � 1 D�- � C�.O 0.�tb�'1 Please return the completed claim form to: �� 0`��M Office of the City Clerk • City of Saint Paul 15 W. Kellogg Blvd. 310 City Hall ; Saint Paul, MN 55102 If you do not return the completed claim fbrm with the appropriate documentation or information completed, then a claim file will NOT be established and an investigation WILL NOT be done. In other words,NO FURTHER ACTION will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances. 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...shall 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 egplain 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 O'�HER DOCUMENTS TO: CIT� CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name ��11(�ti'\ f� . Middle Initial � Last Name '� h�a rr,r,a r°, D , -. _�_ . ompany ----- Are You an Insurance Company? Yes/ T�o If Yes, Claim Number? Street Address City State Zip Code Daytime Phone(_, - Cell Phone(_) - Evening Telephone(_) - Date of Accidentl Injury or Date Discovered �a-�� Time �i�:3� rr �� Please state, in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how y. feel the City of Saint Paul or its employees are involve and/or responsible for your damages. �� `��3 5�ot,� e.rn� t,�i t ec� � �� A�uL. �-�-� r �o o�FL `6�.g , o f�� v" en �'U 1 . .r_^ LG C � r g"�2'-°y � o n O��- �3 d �- -e � � �(�!'►�I/'_ � .C�� '' 1!� � �P�� cn�d ,� � t'� � �, �/� �'Y` e. � Q��L�� '�K-GB�in� G�q\'►'d\- 1�C.�U. �'- T�l `� � S G� Y'�°�.,� �— �r� r�(.t�� . . . Please check the box(es)that most closely represent th reason for complet� g this form: s--� ❑ My vehicle was damaged in an accident �Iy vehicle was damaged during a tow ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow '-"`� -f�-Nfy�e�iicle w�s-wron�€�1�.�-t��ueda�dLc�.�i�ke,k�e.d----..— -- - - .;�.�..,._,�.�0 I_was iniuresl�n.City property ❑ Other type of properly damage—please specify � �� +� —��a ��_ � ❑ Other type of injury—please specify In order to process your claim vou need to include copies of all applicable documents. For the claims types listed below,please be sure to in�lude the documents indicated or it will delay the handling of your claim. Documents WII..L NOT be returned and ecome 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 fo the repairs � 0 Towing claims: legible copies of any ticke�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 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 Unlrnown (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, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. � � Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. r��i � �"h-� h�,`�n�f� � __�-__ ��-�.�� _ Vei�icle Claims-please complete this section ❑ check box if this section does not apply Your Vehicle: Year �U o°� Make �6�o�-� Model ��'!``.'�t�'`� License Plate Number 'oty 0 }-��H Sta.te�'Color : o�(r� l -E Registered Owner ��hV�A '�- hu r�nd� Driver of Vehicle Area Damaged Q o�SSef�a��(�S� � '�L-1 . � �i'��rr� � City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle'(City Employee's Name) Area Damaged In'ur Claims- lease com lete this section ❑ check box if this section does not a 1 How were you injured? j 1� What part(s)of your body were injured? � Have�you sought medical tr�atment? � 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(sy, -- -- - -- - - - ��ar�e of�-£�rrp}cry�r ,_ �- , _,�s--, . _ -�.... ,--�--,-��--_--:-- _ __ 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 prosecutio�z. Date form was completed �/�( �-d �� Print the Name of the Person who Completed this Form: ��lMd` �` � j'L(.i. Signature of Person Making the Claim: ��1/��-O� �--- P Revised February 201 I � St. Paul-Police Department for � Ramsey District Court - RECEI PT ST P,� I"�'°�°�°T 830 B/�RIiE CIVQMEL RU SAINT PAIIL, MI. 55107-295(� 651-266 5642 Date/Time: 02/23/2.013 11:26 Invoice #: 20260 �:`'iot 80i��i4aes Vehicle Plate: 240HBH/MN Sale zzzzzttzzzzzz8124 Payor: OWNER �ocation f'a.id: Impound Snow Lot I�SiERCCpRD Entrv�ethad: S�iaed iotal; f 272,50 02i23i13 11;25;47 Citation: Amount: Inv�: 9906�6 A�ar C�e. �5i42 I�rvd: Online 888761449 $ 53.00 a G�stwuEr CuHr ___ . _ _ _. iFIpM}'qJt Total Amount Paid: $ 53.00 Paid by: CREDIT CARD KEEP THIS COPY FOR YOUR RECORDS �aint Pauf Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form , , Make: 09 TOYOTA License#: 240HSH CN: 13036203 Invoice#:20260 DatelTime Released: 02/23/2013 11:26 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 �iehicle 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 prior to leaving the impound lot. Damage and/or other{�roblem: �`-' `5�7�' 7�S ~�� t� �� . Police Report made: Yes_No_ IF Yes, CN , If NO, �Nhy? T PR TECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFQRE LEAVING THE LOT 5/2000 Signature __