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Spencer NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Minnesota Mi�uresotn S�ate Stntute 466.05 stntes thnt " ...every person...whn clnims damnges.�'rmm�ny mernicipnlity...sltall cnu.re to be presentecf to the ��nverning hurfy of�t/1e municipnlity x�ithi�t /80 duys nfter t/�e c�l/eged lo.rs or injury is discnvered a nntice stctting t/�e lime,p/nce,nruf rircumstnnces thereof;and ilte amounf nf cornpensation or other relief demnnded." 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 bein�;requested. 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 DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First NamP l��?�/�� Middle Initial L• Last N1me � ,��`37��2--� �r"�� - �IVED Company or Business Name � Zt��4 Are You an Insurance Company? Yes No If Yes, Claim Number? �U �- Street Address -/ � �� '7i�//ti J� .��;�7 -� y� � ��Y CLERK � ��l� �— City� /�� State � �/� Zip Code J� Daytime Phone ( ) - Cell Phone (.�O�-��s�Evening Telephone ( ) - Date of Accident/Injury or Date Discovered � �' `�� Time �'�s am/� 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. �.r7 <.-- - � '""� C'. lc��E d x� �L "TD�.cJC-�c� d A ',�v�,v ' u � -r � o ca�� _ � d ,�:� � '`� - -�,��' o. o --�� -- � _ -�- G- _ ; , - �> -r wq - !�� 7�7 T' •�� /F/ ?'�>c� E� � F � �' n --� / � r oc.r� T. d'✓� b� -ti i�o�� Q,�° Gv�_ �� ' � �t 5 i �',� e /5 �° �9.� �91.5o u�o- �' "C= '`7� E� <C-`. � '7 � � d �O � - C'��/�� ,--, c � �'"�4 � � 'd Ll�'._.c.�h��t� ��Z��n ;�� S��T �O/ 3 Please check the box(es) that most closely represent the r�ason 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 and/or ticketed ❑ I was injured on City property `❑1 Other type of Property damage-please specify . `4!1 Other type of injury-please specify /t`1 �F � �� w�_5 O�-l��d� d .o✓�� C,��E-� � 1`��,c' .�,��c�F � i�' i yiF T �' �E"� ln order to process your claim y�� nppd to include copies of all anplicable 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 $ 00.00; or the actual bills and/or receipts for the repairs `�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 claim. All Claims-please 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 call�d? Yes No Unknown (circle) If yes, what department or agency? �� T f7�/ ,��i�r Case#or report# �'�O �'O � 3 9d U 3 J ��1��= L-.Q-/� �w 1 Where did the accident or injury take place? Provide street address,cross street, intersection, name o�ark or facility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. � `�/ � c�iZ e�.� ��E Please indicate the amou t ou are seel:ing in compensation or what you would like the City to do to resolve this claim to your satisfaction. � DD� " ° — "�� F .� - /�c-�c'_7�v i-% ,cz d � o� / - �"��! � O� � _ Vehicle Claims- lease com lete this section ❑ check box if t is section does not a 1 Your Vehicle: Year ��S Make C�a� � .� � Model �_ �cZ�v F Ur F- License Plate Number IG A� State�lit/ Color� �/�F c` Registered Owner dir a� -i� � F�- � � Driver of Vehicle �7� V r �zi� �- �v� -� ��,¢,�r-d Area Dama�ed City Vehicle: Year !'�/-1� Make /l/A� Model � � License Plate Number iN�� State � Color /�- Driver of Vehicle (City Employ e's Name) /✓��- Area Damaged - Inj�ry Claims-please complete this section check box if this section does not applv 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): 'l/ �- Address N� Telephone /� �` Did you miss work as a result of your in�ury? Yes No When did you miss work? i i�- ' (provide date(s)) Name of your Employer: � � Address � Telephone N �- ❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages By sign�ng t)tis form,you are stating that ull information you lzave provided is true and correct to tlze best of your knowledge. Unsigned forms will not be processed. Subrr�itting a false claim can result in prosecution. Date f'orm was completed �` � � �� y Print the Name of the Person who Completed t�iis Form: ��D�' �!/zf' �..-;cC17�E�'_� Signature of'Person Making the Claim: �--'C_-�c-�-�" _' - -�____ Revised Febru��ry 201 I / � � i/1 : � � �� - �� - � .� - �� ..�� . s�l��, � �- n � DEPARTMENT OF POLICE�,� �O v� Thomas E.Smith,Chief of Police �D 4 �/�'1 L7�/��-"c� `7�) �.Q-b � ��pT� CITY OF SAINT PAIJL 367 Grove Street Telephone:651-291-6005 Christopher B.Coleman,Mayor St.Paul,Minnesota 55101 Facsimile:651-266-5711 � CERTIFIED NOTIFICATION LETTER � STATE OF MINNESOTA F�lHivijEY COUNT'r Qat� I�c�tifie�: 12/09/2013 C•N: 13258617 Gate Tovved: 12/04/2013 Totnt �c�cation; DAYTON, 341 tl.I.N.: 1G6KD54Y45U143174 Year and �fla�e: OS CADILLAC Licer�se Nc�: 193KAA �tate: MN �3v�,tt�er; Spencer, Dorothy 1378 Maynard Dr E Ap±218 St Paul Mn 55116 ��-�r��i��: 21887 The above listed vehicle, in which you have a property interest as the owner/lien holder, has been impounded by the Saint Paul Police Department, in accordance with City Legislative Code Chapters 161, 162 and 163, Minnesota Statute 168B.04, or other applicable law. This vehicle was towed to and is being held at the Police Impound Lot, 1129 Cathlin Ave, St. Paul, Minnesota 55108 Claimin�_Vehicle -- Under Minnesota Statutes 168B.051, 168B.07, & 168B.08, you have the right to reclaim the vehicle. Also pursuant to the above statutes, you may have the right to reclaim property from the vehicle.Failure to reclaim the vehicle and/or its contents within the appropriate time allowed and under the conditions set forth in the governing statutes constitutes a waiver of all right,title, and interest in the vehicle and its content. Please see the attached inforxnation for pertinent statute language. If claimed, the vehicle and/or its contents will be released to you upon satisfactory evidence of ownership, insurance and payment of all towing, administrative fees, storage fees and tax. If you do not claim the vehicle andlor its contents within 15 days after legal notice to the owner, it is considered a waiver by you of all right, title, and interest in the vehicle and/or its contents and consent to the transfer of title to and disposal or sale of the vehicle and/or its contents under Minn. Stat. 168B.08. The City will dispose or sell any unclaimed vehicle and/or contents. Per Minn. Stat.§ 168B.051 Subd. 1 & la. AA-ADA-EEO Employer If the vehicle is sold, the City shall first reimburse itself from the sale proceeds for the cost of towing, -- preserving and storing the vehicle, and all administrative, notice and publication, costs incurred. Any remainder from the proceeds shall be held pursuant to Minnesota Statute 168B.08, Subd.3 for the owner of the vehicle or entitled lien holder for 90 days. If there has been no claim on the remainder of the proceeds withi 90 days fter the vehicle sale, it shall be deposited in e City reasu .. Contents in Vehicle If you axe a vehicle owner and can provide to the impound lot operator documenta.tion from a government or nonprofit agency or legal aid office that you are homeless,receive relief based on need, are eligible for legal aid services, or have a household income at or below 50 percent of state median income, you have the unencumbered right to retrieve loose personal property without charge. All other rules of the impound lot still are in effect,party must be registered owner of the vehicle. Please see the attached information for pertinent Omnibus bill language. Please refer to our department's website for additional information on our Impound lot with links to the full text statutes referenced in this letter. Our Website is l�ttp:i:`«.=tiv��.�tnaul.�o��iicidex.as�x?�'Ill=461 . You will also fir.•d:n:,�:::r:p��r,�.�^ �^*' � sor:e q�.:es±inns frequ�r.t?y wske�?of e�ar i:::�our_�l�t staff. F'er f,�r+�?x information call 651-603-6895. Sincerely, TI-�or�as Srr��ith Br�t Smit�� CHIEF OF POLICE Impound Lot Manager AA-ADA-EEO Employer =.ti � . �'��a :�, � � G� • '�{Minnesota 2nd Judicial District �E� . � � � Ramsey County �{LgDUNO�?�� . 6' � �\� ,� 15 W Kellogg Blvci Room 130 �:'3� ��•� Saint Paul MN 55102 � � � � � - _ - ��. � ,l� Phone: (651)�66-9202 '• - - `a' � _ Return This Portion With Your Payment �+i�'"�. � I IIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII(IIII IIIII IIIII IIII('ll � / � DOROTHY SPENCER Citation No(s): 620901390031 � � ��"1 438 MAIN ST APT 439, Plate No.: 193KAA � ST PAUL, MN 55102 � � �� Vehicle Make: ADIL t� � � Pay Before: 02/03/2014 /-�, � � � Balance Due: $61.00 � r1 Date of Notice: 01/06/2014 Amount Enclosed: �c - - - - - -- -- - -- -- -- - - - -- - - - - -- ---- - -- -- - - - -- -- - - -- ILate Payment Advisory and Final Demand Notice A citation for Snow emergency parking restrictions in Ramsey County at 341 DAYTON AV was issued to you,or a vehicle registered in your name on 12/04/13 at 9:55PM.This citation has not been responded to within the required 30 days.A$5.00 late fee has been added to the balance due. If the citation is not paid before 02/03/2014 and you do not appear to contest the violation,a$25.00 delinquent fee will be added to the balance due. Under Minnesota statute 480.15 subd 10c,the District Court may refer any portion of the fine, surcharge, court costs, or fee that you fail io aay by the due date to a collection agency. The Court cannot accept payment for a citation once it has been referred to a collection agency. Additional collections efforts that may occur are: / + Refer your account to a private collection agency ' 1�� L.� � ♦ Offset of your state tax refund (�,,�� t� � � �_ ♦ Tow your vehicle ! ♦ Recommend your driver's license be suspended *� -- t.� ' + Recommend your hunting or fishing privileges be suspended � �� )'� 1 � � �� ♦ Access non-public government data on you for the purpose of collecting this deb`tJv �� / \/ ♦ To contest a citation or collections referral,you must make an appointment to see a hearing officer by calling � ��G�� 651-266-9202 before: 02/03/2014 � ) ♦ You must bring this notice and a photo ID with you when you appear for your appointment. �(� V + Make checks payable to Ramsey District Court. Write the citation number on your check and mail it with the � top section of this notice in the enclosed envelope. G�,�� '� ;� ♦ Do not send cash. J ,y ♦ Please allow 5 business days for processing. k r �� ♦ Pa on the intemet with a check or credit card. www.2ndwebpay.courts.state.mn.us � � `'/ �c Y + To pay by phone with a major credit card call 651-266-9202. Have this notice with you when you call. f c�.' � �1 If you believe this notice has been sent t�you in error please call 651-266-9202. d / � This is Your Final and Only Notic� / {�- 1,l � For your records: Citation#: 620901390031 bffense Date: 12/04/13,Amount Due: $61.00 , ,��,�� , `� � �� `c,l'G . � �. l � ��`� � �� , . .J'� �' � � �� '� ` � .N �;� , ;��M;�l �� i� -��`�Y�� /�/�i�- / '� � � ��%j l /�' L„ n 1/-, .�_ � � . f OFFICE OF HUMAN RESOURCES Angela S.Nale=ny,Director RISK MANAGEMENT CITY OF SAINT PAUL aooc��xarrAnnex Telephone: 651-266-6500 Christopher B.Coleman,Mayor 25 West Fourth Street Facsimile: 651-266-8886 � ,� Saint Paul MN 55102-1631 �'r�� 2 81014 � CI TY C�ERK March 17, 2014 Dorothy L. Spencer 438 Main Street, Apt. 439 Saint Paul, MN 55102 RE: Claim Number: C 140096 Dear Ms. Spencer: Attached please find a property damage release far$606.05 to settle your claim against the City of Saint Paul. You will need to sign the release in the presence of notary public and two witnesses and return it to our office. Once the signed release is returned, a check will be requested and sent to you within thirty business days. Sincerel andra Bodensteiner Claims Manager SB 7 AA-ADA-EEO Employer Property Damage Release File Number C-140096 For the sole consideration of six hundred six dollars and five cents ($606.05), the receipt and sufficiency whereof is hereby acknowledged, the undersigned hereby releases and forever discharges the City of Saint Paul, the Saint Paul Police Department, Impound Lot, their heirs, executors, administrators, agents, and assigns, and all other persons, firms or corporations liable, or who might be liable, none of whom admit any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, to property which has resulted, or may develop in the future from an incident which occurred on or about the 30th day of December, 2013, at or near, Saint Paul, MN. The undersigned hereby declares that the terms of this settiement are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the property damage mentioned above. I hereby state that I have read this release, know the contents thereof, and have signed the same, relying on my own judgment and on no representations of others, and of my own free will and accord this a�'�' day of ��/ , 20 I-5l . In the presence of: Witness Dorothy L. Sp cer •�� Witness Subscribed and sworn t before me on this �� day of `�1��G� , 20 /� � Notary Public � ., ARIANA LYNEL REESE NOTARY PUBLIC-MINNESOTA � MY CpMMISSION IXPIRES 01/31�16