Franklin - RECEI�'ED
MAR 2 4 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn��cTt� CLERK
Minnesotn State Statute 466.05 states that "...every person...who claims damages fram any municipality...shall 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
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 wili 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 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 �1-�'r N Middle Initial�Last Name �✓��M1 k�i n
Company or Business Name
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address �J' 7 y ,/�'I��S hl�.�� �V C _
City ��. P` Au.� State /�/V Zip Code�Z-
Daytime Phone( ) - Cell Phone (�),�- Q'rJ Z�'fEvening Telephone( ) -
Date of Accidend Injury or Date Discovered �Z � ��l � ��j Time � � � /pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel�he Cit;of Saint Paul o�its emplo�ees are involved and/or responsible for your damages. = Ir��!/
ur� tti0 w �B✓ /lG '
,_� �er «Qdr �n� �,.. i,�k �.t! ��ad- d� n, C rDSS ►.,.a.lk�� v-a.�-kw
�--I�n in � �N�w �tM�YA�it�G_T tG e�
Please check the box(es)that most closely represent the 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 0 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 you need to include copies of all applicable documents.
Far 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 aze 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 complete this section
Were there witnesses to the incident? Yes No nknow (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enfarcement 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 poss'ble. If necessary,attach a diagram.
T�� }-ran o� lk.,�k a�� �.,a �ruf� /V �. S+
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.���v�f�N.py,„,�' Le,r �-1,� �--o yy��e G,h,�, Sho�r eN.,6Vww�Gy
_L��-a��`eh . � 2`��+ .SD 'T—
Vehicle Cl�ims-nlease comolete this section ❑ check box if this section does not anvlv
Your Vehicle: Year Z o°'�Make l7 �L� Model
License Plate Number State /�1 Color
Registered Owner�1ikC� FiRhk�tin
Driver of Vehicle .h1�� �,n,1G1�11
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniur�Claims-please complete this section ,B!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):
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�. i
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 � l l � / � �
Print the Name of the Person who Completed this Form: � �'4'Gvt �r�,wk«h
Signature of Person Making the Claim:_J�� ci� 1/�h1✓�1;.�
Revised February 20l i
CITY OF SAINT PAUL
i
TO: Mr. Franklin
FROM: Shannon Adams, Office Assistant III, Impound Lot
SUBJECT: Citation/tow
DATE: March 6, 2014
Dear Mr. Franklin,
On 12/18/13 you had a vehicle with license plate number 453EBA towed to the
Saint Paul Impound Lot with citation #6290901345494 . In working with the
violations bureau it was discovered that the ticket that was placed on your i
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 Paul Police Impound Lot as a Snow Emergency tow. We suggest you fi11 i
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.
We apologize for the mistake and if you have any questions feel free to
contact us 651-266-5642.
Shannon Adams
Office Assistant III-SPPI�Impouncl Lot
830 Barge Channel Rd. �
Saint Paul,MN 55107
ri 651-266-5642 ���
F:651-298-4938
Saint Paul Police Impound Lot, 830 Barge Channel Road, vehicle Release Form
Make: PONTIAC License#: 453EBA CN: 13267540 Invoice#: 23431
Date/Time Released: 12/18/2013 11:15 Tow Charge: $ 123.95 � �j
�`.J
Released to: TOTO Storage Charge: $ 0.00
, Paid by: CREDIT CARD Admin Charge: $ 80.00 `� 1
\.J
Released by: AMANDA 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 oth�r prQWems 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 I
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: 'I
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature 5i2000
i
St. Paul Potice Department for
Ramsey District Court
RECEIPT
Date/Time: 12/18/2013 11:15 Invoice #: 23431
Vehicle Plate: 453EBA/MN
� Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0901345494 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CREDIT CARD
KEEP THIS COPY FOR YOUR RECORDS