Hancuh , RECEIVED
, M�,R 13 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Min�f�sTo�aCLERK
Minnesota State Statute 466.05 states that°...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances 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 w 1 not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,an�the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. �'he 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
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First Name ;� �� Middle Initial��Last Name �/1 ,
Company or Business Name ��.5/����
Are You an Insurance Company? Ye �q! If Yes,Claim Number?
Street Address J'��,3 ��✓ i`�'� �!/�', `
City ����'��o,��'� State � Zip Code �'S��
Daytime Phone( �✓�_���OCell Phone(b��)���w �vening Telephone(t�!)� ����"
Date of Accident/Injury or Date Discovered � / � Time ��So 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 aint P ul or it employee�are involve �and/or resp sible for your damages. �
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ease,,� ���� /� . ��C/�// �J �f��L�/'',�
hec bo�'(es��Ifat� st c ose represen t e rea o or comp g s orm: �
❑ 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 �'���r�
�y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property �'i� ,
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all applicable 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 WII.L 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 repau°s
�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 docume�t and support your claim but will not be retumed.
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? � No Unknow (cir le) 9�� l,���
Provide their names,addresses and telephone numbers: ��/,z��.� , � , O�Y.l'J v� ,
� -- / -/ l�
Were the police or law enforcement called? Yes Unknown (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 po sibl . If necess , attach a di gram. l ,f�
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Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. r� / � r � �
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Vehicle Claims— lease com lete this secti n check box if this section does not a 1
Your Vehicle: Year�po� Make _Model �'7 />!�f
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com lete this section check box if this section does not a 1
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 you are attaching more pages to this claim form. Number of additional pages�. �,
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. ',
Submitfing a false claim can result in prosecution. Date form was completed � 9 � '
Print the Name of the Person who Completed this Form: ����� a'�
Signature of Person Making the Claim:
Revised February 2011
CITY OF SAINT PAUL
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TO: Mr. and Mrs. Hanchu
FROM: Shannon Adams, Office Assistant III, Impound Lot
SUBJECT: Citation/tow
DATE: March 6, 2014
Dear Mr. and Mrs. Hanchu,
On 02/21/14 you had a vehicle with license plate number VGN246 towed to the
Saint Paul Impound Lot with citation #620900196228. In working with the '
violations bureau it was discovered that the ticket that was placed on your '
vehicle was for Parking within 20 feet of a crosswalk. Since the ticket was
not a Snow Emergency ticket the vehicle should not have been towed to the
Saint Pau1 Police Impound Lot as a Snow Emergency tow. We suggest you fill ;
out the enclosed claim form and send it into the city for reimbursement of �
towing and citation fees paid. Also, please contact the Violations Bureau to "
take care of the correct ticket which is also enclosed. li
We apologize for the mistake and if you have any questions feel free to i
contact us 651-266-5642.
Shannon Adams �
Office Assistant III-SPPD Impound Lot
830 Barge Channel Rd.
Saint Paul,MN 55107 �
P:651-266-5642
F:651-298-4938 �
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Pf�8A8LE CAUSE STAT�tiT: The CAiu6PI.AtNFNT t�eing d�ay srnm.makes comploirr b fhs a6ove rsx�ed GouA tMt 1h�1�a.s�
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How Isstaed D i�Pe�son O M�ed �Scene
COURT
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 07 JEEP License#: VGN246 CN: 14033708 Invoice#: 29332
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Date/Time Released: 02/21/2014 21:36 Tow Charge: $ 123.95 �-��-
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: DESHANDRA 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 YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000
St. Paul Police Department for
Ramsey District Court
. RECEIPT
Date/Time: 02/21/2014 21:36 Invoice #: 29332
Vehicle Plate: VGN246/MN
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900196228 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CREDIT CARD '
KEEP THIS COPY FOR YOUR RECORDS ,