Perkins . . r- - - - - --
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RECEIVED
NOTICE OF CLAIM FORM �o the City of Saint Paul, Minneso�� 2 0 2013
Minnesota Smte Statute 4h6.05 states tlmt "...everJ•person...x�ho dnims dnmages from any municipalih�...shaU cawe to be„����E R K
�overning 6ody o(the municipalin�within 180 days qfter the alleged loss or injury is discovered a notice statin�the Onie, c ,
�irrumstunces lkereuf,u�ul dae umoun���jcamper�.catirn�ur nlhrr relirjdrma►ulyd.°
Please complete this form in its entirety by clearly typ�g or printing your answer to each question. If more space is
needed,attach additional sheets. Please note Wat you will not be contacted by telephone to clarify answers,so provide as
much information as neccssary to esplain your claim,and the amount of compensation being tequested. 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 cltim. This form must be signed,and both pages completed. If something does not�pply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102
Firs[Name �c�.�±.� Middle Initial � Last Name !' '� /����� C� �
a m
Company or Business Name � � TL°G� �L✓� � S � � �
Are You an Insurance Company? Yes 10�' If Yes,Claim Number? n p m
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Street Address � �� i+-,n��l� � 3�/ m � m
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City C��m.vL��l� State `�ZSI�v>>��L- Zip Code� ��� � 0
Daytime Phone(��-�Cell Phone( ) - Evening Telephone(_) -
,
Date of AccidenU Injury or Date Discovered � I� �f Time � f� �l pm
Please state,in detail,what occurred(happened),and wriy you are submitting a claim.Please indicate why or how you
feel the City of SainiP.�ul or its em loyees are involved and/or responsible for your damages:�rv. c�,b .n s��t��. —
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f'Ytie Ihy L ci`
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 o the street ❑ My vehicle was damaged by a plov�r
�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 you need to include couies of all a�ulicable 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 WILL 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:iwo estimates for the repairs to your vehicle if[he damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
•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$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always weicome to document and support your claim but will not be retnrned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pagesl will result in delay in the handling of your daim.
All Claims—please complete this section �
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No� Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection1 name of park or facility,
clP sest 1 dm k,etc. Please be as detailed as possible. if necessary,attach a diagram. � (G'C7L� �$/y�,� �t/'eh�t'. ',
�J`7'a �aLr� M�+n�PSd f-�... � ',
Please indicate the amount you r seeking in comp�nsation or what ou woul like he City to do to resolve this claim
to your satisfacti n. t.�d��� � i�p�{�n_ ����%�'Te�Y '�'' C c�S�f s �tc !��-L!�
5� c�;-�-,�-- lN '1� �7�.
i
Vehicle Claims—please com�lete this section � ❑check box if this section does not applv '
Your Vehicle: Year � �1 Make U�s I�� j f' Ivlodel �c./�'.�✓`cc.— �
License Plate Number State�[�Color �
Regis[ered Owner P✓"� . y' �
Driver of Vehicle • �` ��"�C i.
Area Dama ed
City Vehicle: Year�_Make If� /�. Model
License Plate Number 11///L� State�Color '
Driver of Vehicle(Cit Employee's Name)� �
Area Damaged N��
In,�urv Claims—pk�se.complete tivs section ,�check�ax if this section does not appiy --
How were you injured?
What par[(s)of your body were injured?
Have you sought medical[reatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? {provide date(s)j
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 page�to this claim form. Number of addidonal 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 fornts will not be processed.
Submitting a false claim can result in prosecution. Date form was completed � �r��� � t 3
Print the Name of the Person who Completed this Form: J � ( 0� /�,�� � n�'
�l �.
Signature of Person Making the Claim:�r ��" �
Revised Febntary 2011
I
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�------------------ -----
� �,.- � � Impound Lot, 830 Barge Channel Road, Vehicle Release Form
�
,,•�''"�^ - BILE License#: 336RNW CN: 13168255 Invoice#: 145822
i
� � : 08/09/2013 10:01 Tow Charge: $ 54.50
POU�O�Di Storage Charge: $ 0.00
,T PA�� i�cN��NEL��qy� �
S�0 BpRGE `I ��1pj 2 RD Admin Charge: $ 80.00
�n�5642
SR1Ni P651�266�
Tax: (7.625%) $ 10.26 i
1lerchant 0�173 00008�a638�1440�
�e�m I� C�le � recovered the vehicle descrbed above. Subtotal: $ 144.76 �
� far damage or any other probl.ern�that ;
� �e±his vehicle was in the.�uStasip_c�f�he S�ice Char e $ 0.00 �
— xxxxXxxxxxxz2b0� Entry M�th�d'S��p�� tment. i acknowieage � wiu report � - �
yiSP � 1QQ. .r problems to the Impound Lot staff Total Charges: $ 144J6 ,
ing the impound lot. :
�otal'. lp�,(��.49
�3i49�13 Ppar CodE`_°3�R� �blem:
`n��;� ;
� _No_IF Yes, CN , If NO, Why?
� + �HTS, REPORT ANY PR�BLEMS/DAMAGE BEFORE LEAVING THE LOT
.Caa�
c„slo�aC�
`H�K y0U! 5/2000 �