Masanz NOTICE OF CLAIM I�'ORM to the City of Saint Paul, Minnesota
Minitesotu State Stcrtute 466.05 stcites that "...enery person...wlto ciciin�s danitrges frona any ititmicipa]ity...shnll cciu,se!n he pre.cented to the
gorerning budy qf the i�rcuircipa(iry wrthin I80 days c{/ter tMe nlleKed loss or injury is discovered a nutice stntirtg the tinie,p(uce,curei
circinnstances theren�;nnd the nmount o/�compensntrrnt or olher relief demnnrled."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more s�ace 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 explain your claim,and the amount of'compensation being rec�uested. You will receive a
written acknowled�ement 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 OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name t��y� Middle Initial .� Last Name �v`S��tn'Z� RECEI�f�p
Company or Business Name SE'P 1 "� �13
Are You an Insurance Company? Yes No If Yes, Claim Number? C�.ITY,—��`-�K
Street Address ��l`� ��� S� ,
City � , �VL State �" `� Zip Code �`���Z
Daytime Phone (��� )�-��Cell Phone ( ) - Evening Telephone ( ) -
Date of Accident/Injury or Date Discovered ��f�" �� Time •�am/�
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you
feel t^h1e City of Saint Paul or its employees are involved and/or responsible for your damages. \ i'����� i,vc�S
W�'J�`�n°"�1 �, !`^- 5 � U� y`H,� �vU � 7r ►�o � 1��Sv�.., dn I_�tt�+,.i•
� � �s N w�yS
Please check the box(es) that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident �y vehicle was damaged during a tow
_D,My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
�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�u need to include conies of all annlicable 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: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O 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 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 daim.
All Claims–qlease 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 nknow (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. 2��� Cb�{��e S�t•
Please indicate the ount ou are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction ���� ��
Vehicle Claims– lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year �� Make �r/iJR Model TN7�G �4
License Plate Number����--I�T L — State�►'v Color W ��'E
Registered Owner ke�'� � ��=5�h-2
Driver of Vehicle t �
Area Damaged���c,�ft� � �h'�ec'� �� C�����
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injurv Claims–please complete this section ❑ check box if this section does not apply
How were you injured'?
What part(s)of your body were injured?
Have you sought medical treatment? Ye5 No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
I�1ame 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 moi•e pages to this claim furm. Number of additional pages
I3y signiiag tlzis form,you are statircg tlzat all informatiora you lzave provided is true and eorrect to the best
of your knowledge. Ufzsigned forms will not be proeessed.
Submittirzg a false claim can result i�z prosecutiofz. Date form was completed �� I r l�
Print the Name of the Person who Completed this Form: ������ �`�`S�`�Z
Signature of'Person Making the Claim: IU��'.��
Revised February 201 I
Saint Paul Fofi�e Impound Lot. 830 Barge Channel Road, Vehicle Release Form
Make: 91 ACURA License#: 466DTL CN� 13075375 Invoice# 14398?
Date/Time Released: 04/25/2013 18:2� Tow Charge: $ 54.5Q
Reieased to: 70T0 Storage Charge: $ 105.00
Paid by: CASH Admin Charge: $ 80.00
Reieased by: DORIS Tax: (7.625%) $ 10.26
I,ihe undersigned,have recovered the vehicie described above. Subtotal: $ 249.76
I w�il check the vehicfs ft�r damage or any otner prablems that
mGy have occurred whi!e this vehicle was in the custody of ihe Se�vice C�arge� $ �.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 249.'6
on this form prior t� ieaving the impound iot.
�amage and/or other problem:
Police Report made: Yes_ No_IF Yes, CN , If NO, Why?
TO PRO i ECT YOUR RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000
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