Shatek � ����������s�e�� ���r F����� ��a��ce� o�� ��aE€��� �a �i�y o�€ �aE�a� �a�€� � '.:�
Minnesota State Statute 466.05 NOTICE OF CLA/M.,.(EJvery person...who claims damages from any
municipality...shall cause to be presented to the goveming body of the municipality �vithin 180 days arter the
al/eged loss or iniu�y is discove�ed a notice srating the time, place, and circumstances thereof, and the amount or
compensation or other�elief demanded.
Flease compiete this for��� in its entirety by typing or printing your answer to each questio� in
the space provided. If additional space is needed, please attach addition�l sheets.
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- - PLEASE RETURN l�HIS Office of City Clerlc q(/ ��FO
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COMPLETED FORM T0: 170 Cit Hafl � ,3
15 W lCello Blvd,' ?�
99
St Paul MN 55102 ��/4�
Yo u r N a m e: �a,G��G�L��°�I.GI _ �..J r l�.t,�_---- _ -- .
--Street-Adclress: _��j�j"�(X�Ct"►`l�. y��7t��i'�L�� --- _.-- ___._ __.-- .____--- -----_____ _ __ -- -- -----. ---... __:_
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City: ���� ���� l State; �r� � Zip Code:
Daytime Telephone: __����) �� .�1 ����� � Evening Telephone: ( �c��v�l i�U� "��c��/
Date of Accident or Incident: �� Z � �Day of Weel<: ��IG�YIL�(,Q.t- Time; �� am r pm (circle one) ,
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p��dSE StB�°, !(1 �°+81�, b^J�lu�t OCCUrred 8'1G' t�?° Cl�CJ�^�S?H�1CBS surrcundin� the event. Indicate how the
City of Saint Paul is involved, and why you feel the City is responsible. .
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Piease indicate your reason for completing t�iis form: ��;�y .��L
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f...l Vefiicte accident 1--7 Other property damage (please provide specifics below) ';;;il:
�i Vehicle was towed ' i�'
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❑ Vehicle damaged ❑ Other injury to person (please provide specifics below) `��`
❑ Slipped and fell on City property :':���I'
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Please provide the names and telephone numbers of any City employees involved in this � ;
incident/accident and I�ow tl�ey were involved: j
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If your vehicle �n�as involved, please complete ihe follo�n�ing: O � � ��
1'ear, mal:e, and mooel: �,�Q.�"t� --j;'j�1C✓l}� �Llv � G� ` �5 License Plate Number.
Extent and area damaged: Qy a - :_y-� q � �ti , /��l'j
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Was a City vehicle involved in this accident/incident? 1'es No (circle one) �wt�t !P v����(
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If yes, please complete the following: Type of vehicle
Year, mal<e, and model
� Color of vehicle License Plate Number: -
Descri��tion of vel�icle
Location of accident/incident (please provide specifics sucl� as street address, intersection, cross streets,
park name, facility name; etc.):
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_ _P.lease.draw_.or.attach.a_diagr_am_if a��IicaUle: '
Please specify the nature and extent of tl�e compensation or other relief you are requesting. Please
attach copies of 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,
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Were there �.Nitnesses to this accident/incident? Yes No , ircle one) �Q'tC� 1GP_ ��7y
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If yes, please give the names, addresses, and telephone numbers of the witnesses:
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Were the olice called. Yes No (circle one If es, what de artment or a enc ? � '
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Police report number: (�� Gj�(;) � �j�3qZ.� ,� C�I�Zi��1G�'1 Irt �i-+'Y1bCl�'' �
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Please print the name of ihe ,
person completing this form: , S� �/l Cl..y'���;{ .�� (;�,�� -
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Please sign your name: + it z'YtGt,yl'f�' l:� ���Z���� j'
Daie form signed: __��( ,-�j�� �
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Saint Paul Police Impound Lot, 830 Barge Channei Rc�ad, V�ete Release FoRn
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Make: 95 CHEVROLET License#: 046EKD CN: �31�� Invoice#: 145879
Date�me Released: 08/14/2013 17:05 Torr�ge: $ 54.50
Released to: TOTO j Si�rage Charge: $ 30.00
Paid by: CREDIT CARD ��arge: $ 80.00
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Released by: BECKY Ta�e�7.625°/a) $ 10.26 �
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I,the undersigned,have recovered thevehicle described abov�. St�fat: $ 174.76 ' `�`
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1 will check the vehicle for damage or any other problems tha# 3 � �
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may have occuRed while this vehicte was in the custody of the ��harge: $ 0.00 , ��,�
Saint Paul Police Department I acknewfedge 1 will report ��� �
damage and/or any other problems to the tmpound Lot staff T�{��arges: $ 174.76 �` 4 4,
on this form prior to leaving the impound lot ;� ,
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Damage and/or other prob(errL "
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Police Report made:Yes_No IF Yes, CN . If IVCl,�Ifi}P�' �`��
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TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMSi#3A1Y�E�±f�'2E LEAII�i���:_.. '�
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Signature �'x�
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