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Paulsen RECEIVED APR 10 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota LERK 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 additionaf 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 depending on the nature of your claim. This form must be signed,and both pages completed. If something dces 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 �d +� I Middle Initial�Last Name �T� � 1– -s � N Company or Business Name /�/� TT Are You an Insurance Company? Ye /No If Yes,Claim Number? Street Address d L �, �. City � � State �� Zip Code -S��p Daytime Phone�)7r,r- 3/'�Cell Phone��/ }5��Evening Telephone(�) S�M� Date of Accidenb Injury or Date Discovered � ��.3 —�O/� Time ��5 am 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. A � �' / � ��%D C9 /u w -�l�j-� �� F��/ .`�tL�lt�� - , � / Please check the box(es)that most closely represent the reason for completing this form: ❑ vehicle was dama e ' �va�i ent � My vehicle was damaged during a tow (�'�y vehicle was.da� condition of t e street ❑My vehicle was damaged by a plow ❑My vehicle was wrongfully towed and/or tickete ��/—� ❑I was in'ured on City property ❑ Other type of property damage–please specify G!N ►� U� . 4 xl A d Lv�� .�-- lt5 /� . ❑ Other type of injury–please specify � �//�'/ l�(._S' / In order to process your claim vou need to include copies of all auulicable dceuments. �� i For the claims types listed below,please be sure to include the documents indicated or it will delay the handli g of W�q. �r(� 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 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—please comnlete this section Were there witnesses to the incident? Yes No Unknown circle) Provide their nam s,addresses and te phone numbers: .� G � � � � � � � c� cuQ�e xt �� 1 i vE M� Were the police or law enforcement called? Yes No Unkn wn (circle) W�.�� 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 1a�tmark,etc. lease be as detaile as possible. If necessary,attach a diagram. OAi 1'�o S z� �Cfit��'P N'_��f�'�"� �#- �'r�'C��v /Q/F/P Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve thi claim to our�arisfaction. °� G � E ' / / � fi��I��l��'�t� oV't �J�lC �fl�c�''1� jS ��t1�G/7 F.� Vehicle Claims— lease com lete this sectio ` check box if this section dce ot a 1 Your Vehicle: Year Make Model 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 Iniurv Claims—ulease 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 you are attaching more pages to this claim form. Number of additional pages 3 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 �"— ! � �� Print the Name of the Person who Completed this rm: CS D�N j'� �''s��1/ Signature of Person Making the Claim: � C Revised February 2011 . I . • • • Date O` — � � _ `� � 1 - Twin C ties i;,;,;�� . Make ��' Transport & Recovery, Inc. License r�� ;�� %� �- 3201 Stinson Bivd. P.�. BOX 17041 2741 Geneva Ave N. Color ( �-�"� St.Anthony, MN 55418 St. Paul, MN 55117 Oakdale, MN 55128 PO# I (651) 642-1446 Call# 1�/ Keys � Odometer /��/ �ocation ��: }�_ �;,.� �l,c. `a VIN#1� �-� � f��C.� � 5 � ��1� <�.'r:j-� � T , Deliver to Charges in Detail � �-, ��---- Driver Ho[5t � �� Special lnfr� b��E�� lT��or n� ._ �� _ � � � � � � _ ��,� � �� - 5.��,,� �,.; �,� . . ' k . �. � ' t ? i' V � �� *N ''� ' � �u�� Owner i� ,� A�tvanced charges: � �`� � ' � �_` � �,� ' ��._ - i C��ri t� �. �r �� ` �ys storage� --�- ��r ��; � �� I , 5�� ..� k .k`�t .r � 4 '�,��` �� ,,.,...�� , ^ j � � " � , ,.• � '�� .. .�"'� �� ` ..� � � ��.`'� 'fi S�' Add�� . - � ;;`� �,1� � �---- /�!,` �'� _�=' �' �''� Total � � �f. � � I Bill To: Cash � Charge on Account � Check# � Auth # � I ---;�__ ! Credit Auth# �r-�� , I i Twin Cities Transport 8 Recovery,Inc.and its employees assume no responsibility /� for damage or theft while vehicle is being winched,towed,or in storage. �}�7 9�-F 5 ICP2110010 White-Office Yellow-Customer Pink-Customer Gold-Office (retain in book) � *CI-StPaul_DS(Complaints Below is the link on the City's website to where to file a claim. -----Original Message----- From: noreply@civicplus.com [ ] Sent: Friday, February 28, 2014 2:20 PM To: *CI-StPaul_DSIComplaints Subject: Online Form Submittal: Ask a Question/ Report a Problem The following form was submitted via your website:Ask a Question/ Report a Problem Your Name: Dorothy Paulsen Your Address: 749 Magnolia Avenue East Phone Number: 651-7743959 Email Address: dotlloydbeck@msn.com Please select the category for your concern.: Right of Way Obstruction and Signs Brief Description Question (or other problem not listed):The City road on Rose Ave between Payne Ave an reenbrier is not paved and not plowed with no warning sign or barrier. On Feb. 13,201�it was dark at 8:15 pm; it looked like the road was okay to drive thru Eastward to Greenbrier, but after - about 1/3 of the way in, I got stuck in the middle of the street and had to have my van towed back to Payne Ave (I had crossed Payne on Rose heading East). I called the City Clerk the next day to report this and she told me I could file a claim at this website. Based on the above facts, I feel that the City should reimburse my$134.53 towing bill I had to pay Twin Cities Transport& Recovery, Inc. in St. Paul. Street Address: See above. Intersecting Street (if applicable): Describe the location in detail. (eg. behind garage, next to front steps, etc.): See brief description box above. Additional Information: Form submitted on: 2/28/2014 2:19:47 PM Submitted from IP Address: 71.34.10.214 Referrer Page: No Referrer- Direct Link Form Address: