Kehrer JnId �1 '?U1-�;'TUE 11 : OG ATdI FA'1� ':��i��, P, 001
N"OT�CE OF CLA��VI FQ►Y� to the +City of Saint Paui, M�nneso�a
Min,resota State Sta�ute 466.1J5 srates that "...every person._.who claims llamages frorn nriy m�rnicipnlrty...shrsll cnuse Co be presented to the
govern.ing bod}�of tl�e mainicrpnlity l+�jihirt 180 days afTer the n/Xeged loss or in.jr�ry iS ClisCOveretl ct rcnri�•e sta[irrg the time,place,ancl
circtunsrcrn.cts therenf,nnd rhe mnorrnr of comper:si�rion or orher relief cle�nerraded.°
�'lease complete th�s#'ortn�n its entirety bv ctearl�typing az�printing yo�ur ansrv�er to eacli q«estioz�. Xf more speCe iS
needed,atfach additionnl sbeets. please note tk�at�ou will not be cu�taeted by telepho�ne to clarify answers,So prp�vicle as
much informtttion s�s�necess�ry to e�tplain your claim,and.tlie amount ai'compensation being rec�tiesfed. Xou will recei�c�e A
written acknowlec3gement once�your foirm is recei�ved. '�k�e process can tal�e up to ten weeks or longer depending on the
nah�re of your c�ain�. This form m��st be sig�ed,and both�ages completed. If something does�ot apply,write`N/A'.
SEND COMYT..�'x'ED FORM A.NA OTIIER DOCUMEN'�'S T4: C�T'Y CLE��,
75 V�'EST �I.L4G-G BLV�]�, 3x0 GITY�I-�AL� L, SAXN'T �AUL, MN 55102
�'irst Name
d iVlicldle�tial��,ast Name K2 I^YQ 1� ���LUE D
Gozzapar�y or Business Name �14
A�e You ar��nsursnce Company`? �Yes/� if Yes, Claim T�Tutxiber? R�
Street Address ZG� y � � �1� � C'� - ` I --
Czty . �l� StaCe�, ���v Zi�Code �5��
Dayti4ne Phone�� -�Cel1 Phone (�������ve,n.i�g Telephone( ) -
Date of Accidend Tnj��ry or Date Discovered �Jn1Y1 ��i Z'��� Time�_�pm
please state,in det�il, vvhat occuzxed(hflppened},and why you are submztuixg a claim. Please indicflte why or how you
feel the City of Sxint p�ul or its employees are invoYved and/or responsible f�r y�ur dainages.
— C' � � � —��-�____�
Please check the bax(es)that inost closely represent ikae reason for compleung this fonn:
�My vehicle was damaged in an acciclent ❑ My vehicle was dazi�aged during a to�'
Ci My vehicle was damaged by a poCho]E or condition of the str.eet ❑My ve�icle was dama�ed by a plow
�1VTy vehicle was wrongfully ta�ed and/or ticketed ❑ I'vvas injured on City property
� Other type of property damage–Please specify .Y
❑ Other type of injury–please s�ecify "
In order to pr•ocess youz clain�,�ou neecl to iiacX2idc�c�opies Of aIl appiicat�le dacr�ments.
�'or the claims types listed beloW,p�ease Ue sttre to inc7ucle tk�e documents indicated or it will del�y the hand�xng of
your claim. Documents W�.L T be returnec�and become the�ro�erty of the City. 'Y�ou are encouraged to keep a
copy for yourself beEore subnnictrng your claim forxin.
O Property dtimage clain-ss to a vehiele:two estimates for t�he repaz�s to your vekuele if the dfunage exceeds
$SUU.�O; ar the actual bzlls and/or receipts for the repsirs
C) Towing claims: le�ible cop7es of finy ticket issued and a copy of the imgo�Fnd lot receipt
O Other property damage ctaims:two rep�i.r estimates if the damage exceeds$500.00;ox rhe aetual bills
aaxd/or rec�ipts for the repairs; detazl�d list of damaged items
� Injiuy claims: medieal bzl.ls,�receipts .
O ph4to�raph5�.re aL�ovays welcome to docmnent and stypport your claim but rwiil not be returnerl.
Page 1 of�–Plcase complete a�td xeturn 6ath p�ges of Claim Form
�:�._. =1,'?01-� �iC�E ' i �'�!:, �.p��T �� �_��. ?; . F, 00�
.
�'ailure tp complete and return�both pages will resuMt i�c�elay in the handling of your claim.
All C�aims—please c�mnleCe t�iis seet�on.
Were these witr�ess�s to the iiicidez�t? 'Yes � Unknown (circle}
Provide thei.r npnraes,add�•esses and telephone numbers: �.w.�_ '
Were the police otr�aw enforcement eaIled? Yes �� Unknown (czrcle)
If yes;what department ar agency? ,_ Case#or report#
Where did the accident or ir�jury ts�ce�lace? 1'rovid�stTeet$ddress,cross street,intersee�ion,�arrxe of park or facility,
closest landmat•k, etc. P1e1se be as detaiied as ossible. If rieeessary,Iltta.ch a dia am.
1� l7'(ZY��'{� �?� �U�n St d- ���'
Ylease indicAte th�amount yau are seekin�in co�xxpensation ar what you would like the Ciry to do to resolve tIus claim
to your satisfacrion.`__ _ —�----
Vehicle Claims ulease coniplete t.his secti4n _�check box if this section does not�pplv
Your Vehicle: Year 1Vlal:e Model
Lieense Plate Number State Color
Regist.ered Owr�e�r _�
Driver of Vehicle ,,,.,_,.__—
,A.rea Darna�ed _�,..�„_
City�V'ehic2e: Y'ear _M�ke� Model
L,icense plate N'umber State Color
Driver of Vehicle(City�m�ioyee's Name)
Area bamagecl _.
��iury Clain�s—please con�ntete this seetion �check box if this sectio►�does not a�vlv �
How were you injured? �
Wlaat part(s)o�your�ody wexe injux•ed? ~
�Txve you sought medieal treatment? Yes No 1'la��ning to Seek TYeatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s): w._
Address _,�_ Telephone _��u__�
Did you miss work as a result o#your injury? Xes � No
R'hen did you�niss woY•k? �_�_. (provide date(s))
N'ame of you�r�niployer:
A,ddress Te�epho�ae
�Check here if�ou are attachinb more�age�;to this claim form_ Number of additiunal pages �
I3y sigr�ing tlais,f'orm,yor��xre stating that all information you have�srov�`ed is true und correct to tlie best
n f your knowleclge. Unsignecl fnrms ►vrCl riot l��processed.
Submitting a false cic�ian can result zri prvseccctiori. Date�orraa was completed �� Z� I �� _ _
P�ix�t the hYa�zxe of#k�e Person who Completed thi �orm: � �� � ' �� Y\Y� r-� —
Signature of Person Ntaking the C1ai�:
Revised Februazy 2011
On January 19th, my husband and I woke up to find that both our vehicles were
towed. We had not realized it had been a snow emergency. Needless to say we had
to pay tow and ticket fees for both our vehicles from the impound lot. We have
photographic proof that the whole "ticket and tow" during a snow emergency was
done unfairly. Both our vehicles were towed but our neighbor's vehicle was left
alone. We did not see a ticket on their windshield. Instead the plow, plowed around
their vehicle. Further up the block, the same thing happened where the plow just
plowed around the vehicle and no ticket or tow. Even more down the block where
vehicles were just plowed around. We had even less snow where our cars were
parked than where one of the vehicles in the photos provided was parked. If your
policy says all vehicles will be ticketed and towed if parked during the snow
emergency, then obviously this was not upheld. Plus plowing around the cars does
not adhere to your "plowing to the curb" policy. We paid $219.50 tow fee for each
vehicle and $56 ticket fee for each vehicle totaling$551.00. We request a full
amount refunded back to us. As photographic proof shows that 5 vehicles within a
two-block radius of our house were not ticketed or towed according to your "Snow
Emergency" Policies. Please see all attached photos.
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St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 01/19/2014 08:40 Invoice #: 26374
Vehicle Plate: 546DAJ/MN
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900208978 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CASH
KEEP THIS COPY FOR YOUR RECORDS
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 98 TOYOTA License#: 546DAJ CN: 14011327 Invoice#: 26374
Date/Time Released: 01/19/2014 08:40 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CASH Admin Charge: $ 80.00
Released by: KAYLA Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made:Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT Y UR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature ,V�� s�2000
�
Saint Paul Police Impound �ot, 830 Barge Channel Road, Vehicle Release Form
Make: 13 MAZDA License#: 039KFZ CN: 14011327 Invoice#: 26356
Date/Time Released: 01/19/2014 08:36 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00 .
Paid by: CASH Admin Charge: $ 80.00
Released by: KAYLA Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made:Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YO R RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature (�-�-p�✓ 5/2000
St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 01/19/2014 08:36 Invoice #: 26356
Vehicle Plate: 039KFZ/
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900208979 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CASH
KEEP THIS COPY FOR YOUR RECORDS