Imholte 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...shaU cause to be presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
czrcumstances 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 explain 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 depencling on the
nature oF your claim. This form must be signed,and both pages completed. ll'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��,(�P, Middle Initial�Last Name =M K OLT� R F�'���I�p
Company or Business Name nrT�L0�3
Are You an Insurance Company? Yes/� If Yes,Claim Number? E�K
Street Address 9�, �4�WS61� AtJe �•
City S�' l��Ull.. State M 1�1 Zip Code 55 I0 t�
Daytime Phone(��-05�1� Cell Phone( ) - Evening Telephone(f�5�J�-C�71
Date of Accidend Injury or Date Discovered 9"u0'��3 Time 1 D_ : O_�/pm
Please state,in detail,what occurred(happened)>and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
Pte�� see att'atl�a6�,'�a�".
Please check the box(es)that most closely represent th@ 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 of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed andlor ticketed ❑I was injured on City property
�"Other type of property darnage—please specify ► ��� bri c.�.5 �-crr�r+ 1'11�t 5 i}�i Y1S WC<«•
❑ Other type of injury—please specify
In order to process your claim vou need to include coaies 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 retumed and become the property of the City. You are encouraged to keep a �
copy for yourself before submitdng 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
andlor 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—nlease comnlete this section
Were there witnesses to the incident? Yes No �own (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? � No Unknown (circle
If yes,what department or agency? �1l Case#or report# I 3 2 D S�Q 7
C i- ♦.
Where did the accident or injury take place? Provide street address,cross street, intersection,name of pazk or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. M�I �cY4��
Si�_ i1r� wa(.i — rotc2n CK15P�.
Please indicate the unt you aze seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. •� r" `�• '�'
'� t� 't ,� H
Vehicle Claims—please complete this secNon ❑check box if this secrion does not apnlv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle '
Area Damaged
City Vehicle: Yeaz Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please comnlete this section ❑check box if this section does not anvlv
How were you injured?
What part(s)of your body were injured? ,
Have you sought medical treatment? 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(s))
Name of your Employer:
Address Telephone
"�Check here if ou are attaching more pages to this claim form. Number of additional pages
E�c pl ana.�'i an 0.�4}ac.hed.•
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 prosecution. Date form was completed 1 D— l� ^ z� ��
Print the Name of the Person who Completed this Form: oe le �innhoi�
Signature of Person Mal�ng the Claim:
Revised February 2011
Joelle imholte
924 Lawson Avenue East
St. Paul, MN 55106
651-644-0571
To Whom This May Concern:
On 9-26-2013 Curtis Banks broke into my home, damaging my two doors. My neighbors alerted the
police, and apprehended the suspect inside my home. An attempt was made to call me, but the
officers said they only had my home phone number. (Had they spent iwo minutes googling me they
would have found my work phone quite easily.) So they called for a "board-up" and now I am being
assessed for these damages. The police failed to note that they damaged my sitting wall when they
attempted to obtain a brick to break down the door of my house. The information I received back
from the police department is incorrect as it was stated in an emai( to me:
°The same officer did note in his report that he took a loose stone from
the wall, in speaking to him he told me when he picked it up it was
loose and didn� damage the wall."
This information is completely wrong - since the brick that was eventually used, did not match those
on my sitting wall, but had been located along the side of my garage, as that was the one I found on
the steps when I returned home. However, an attempt to remove a brick from my wall did cause it to
break loose as these photos clearly show. I'm sure in the fury of what was taking place it was not
noted the damages, but you can see from the attached photos the wall has been moved from its
place.
I think what was so upsetting was the fact that I had been victimized first by the thief, but felt
mistreated by the police department as well. There is no way a sheet of plywood and those few
screws that were supposedly used to secure my property came anywhere near the $443.90 that I'm
being assessed by the city - but what galls me is that I wasn't even given the option. A sheet of
plywood as I note costs under $25.00 from Home Depot, and screw - around $5.00. And, in fact, it
still took no more than fifteen minutes to re-ent�r my home with a screw-driver. Now, I do understand
you were following procedures, doing your best in this situation, but it bothers me that I was not
consulted on any of these things, only to come home to wondering what had happened to my home in
my absence.
I know what is past is past, but I do hope that you will at the very minimum do the next best thing. I'm
asking that you remove $250.00 for the cost of the repairs of my sitting wall from my assessment of
the damages, and then I will agreed to pay the remainder of the damages. I know there is an appeal
process, but I'm quite sure that would require me to take yet another day away from my work and
from my students, and not be the best option all the way around. Please consider this a fair request,
as a way to rectify what I feel has been an unjust treatment towards me.
Sincerely,
Jo e Imholte
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