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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. • �YFcF - - PLEASE RETURN l�HIS Office of City Clerlc q(/ ��FO �1� 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�� --- _.-- ___._ __.-- .____--- -----_____ _ __ -- -- -----. ---... __:_ � � 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) , - . � , 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. . � �.;,- C r � � D •Y� �✓1 I,t S �' `1 �cz. < <n � mc�n c .z I r r� n I fY� v� �. � , r ' c�✓►�e- ' r ct t- w� 5 iM,s sr Yc4 c� 1�1 c�c' _1- ' c o b� C -t � z� r �' � ` �- � vwGt S -- (,E.t� t,i Q Ve ,� � �T' J Vt o1��,e . Pi c�,�� vLeu.�'-�is ie '� -�a�w�c�cc.� �rea �r �11r�t �r.��ss o 9 r Piease indicate your reason for completing t�iis form: ��;�y .��L � � � ,. ;, f...l Vefiicte accident 1--7 Other property damage (please provide specifics below) ';;;il: �i Vehicle was towed ' i�' .�.�: ❑ Vehicle damaged ❑ Other injury to person (please provide specifics below) `��` ❑ Slipped and fell on City property :':���I' ;::; :�;��; �,` ; Please provide the names and telephone numbers of any City employees involved in this � ; incident/accident and I�ow tl�ey were involved: j �--�, • ;� '�- � re� wl�� ►� �,�l�i i� v��c . I : QG� � ; � � ' ,� � �. � - � � ' � (over) ` E . U; , , , 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 C �c� c`�� -�;Y �� -{� � i I� v�' U�� S i v�e.e � '�-�S rJ �v�� ,� , Was a City vehicle involved in this accident/incident? 1'es No (circle one) �wt�t !P v����( �}z�l.�-� 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.): 1 . � �1 d C"c{ r l�4� `1/'t�r'1 ,�'� � cX.,�-r1� ���--Y (�`� : � � , _ _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, � 0.i.YVl,1.� ; ,. ''Y '1 GZ - G'Y� � 1� • �l,1.,,�.G ^ l 1 , -- � ,� .v � L ' r. • Were there �.Nitnesses to this accident/incident? Yes No , ircle one) �Q'tC� 1GP_ ��7y J If yes, please give the names, addresses, and telephone numbers of the witnesses: �_ , Were the olice called. Yes No (circle one If es, what de artment or a enc ? � ' P ) Y P 9 Y• �' �� (� "' �C��Gl..� Police report number: (�� Gj�(;) � �j�3qZ.� ,� C�I�Zi��1G�'1 Irt �i-+'Y1bCl�'' � ��.�1�-� f�u,-e�� Please print the name of ihe , person completing this form: , S� �/l Cl..y'���;{ .�� (;�,�� - , � Please sign your name: + it z'YtGt,yl'f�' l:� ���Z���� j' Daie form signed: __��( ,-�j�� � i —�— i::, Risl< Mgmt Division - Revised 1-30-01 ;;�j!j,�i.', fil;:,); a, `;!a:,9 r,.: .Ir;.il`�: '�1tM11 .sao�r,a�p�� ' �. 6�I� :apo�,� 1 r�:p�dad _ b£68�1i iT�b� 91'b1i � �'� 'p°4�1(��3 �I�1 1� a 5 Te� :��� ;� 8966 � t ��s� � ��.L,T88 3�� �tt�`�y��r;r. Zfi95-99�-IS9 � ���t` ;� �xy :,, � ��18T96 'Ml'•7r�pd 1NItlS ��� � ��#fltlFp�121yg g�g u r�� a�`t ini anp,ur y�y,�ic r,.; �� r� . !� "� ��= F��' -�'�.r �h3°� � a��� �. -- ` �,: �; � `3 Ys ��� 1 ,�i: �t R� x� � � ���` � t ; � �.�'k .�i;` -pr., � , � s*-� �y _�'- Saint Paul Police Impound Lot, 830 Barge Channei Rc�ad, V�ete Release FoRn �--� 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 rz`Fai,, Released by: BECKY Ta�e�7.625°/a) $ 10.26 � �"�� i I,the undersigned,have recovered thevehicle described abov�. St�fat: $ 174.76 ' `�` x� � 1 will check the vehicle for damage or any other problems tha# 3 � � :'f�� �+ 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 ;� , M; Damage and/or other prob(errL " ,� �` r � Police Report made:Yes_No IF Yes, CN . If IVCl,�Ifi}P�' �`�� _� �k.'«3. TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMSi#3A1Y�E�±f�'2E LEAII�i���:_.. '� ��i.. a�': Signature �'x� .� �,f= „�i; .