Vang, Hnee (2) ��������
SUN 11 2014
NOTICE OF CLAIM FORM to the City of 5aint Paul, Min
�� CL.���
Minnesota State Statute 466.05 states that °...every person...who claims damages,From any�nunicipality...shall cause to be presented to the
governing body of t/Te rnunicipulity wi�hi�i]80 ctays after the alleged loss or injury!s drscovered a notice stuting the tirne,place,and
circum,rtance,r thereof,and the nmount of compensntion 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 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 does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY �'LERK,
15 WEST KELLOGG �LVD, 310 CITY HAL�. SAINT PAUL, MN 55102
First Name H N � E , iddle Initial I Last Name_ V �1� �
��1'
Company or Business Name N ��
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address � ��q t �7�M 1-'cs /�J'�
City J���� ��U �. State �N Zip Code ���
Daytime Phone(bSl )�-'�bb Cell Phone ((oSl )2�t��Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 5� 2-1 l 2 O�`} Time 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.
�0.S2. .s�e Wr i-I�e.►� A qc�v�r►P�' �` �
��'�,Z'r`v E D
�
01� �
i
RK
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 ❑ My vehicle was damaged by a plow ,
! My��ehicle�r�as wrengfully t^we�and/or ticketed ❑ I was injurerl an City pra�erty
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include conies of all aaulicable documents.
For the claims types]isted 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 andlor receipts for the repairs ,.,. � � ; t" t- `,
• Towing claims: legible copies of any ticket issued and a copy of the impound lof`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 �'';��+ �!_ � �i�}�
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will noX�,e,returned,..,.:. .,,.-,. .
,.> _�. � , ,. . _ -.
Page 1 of 2—Please complete and return both pages of Claim F'arri�i '4�' �` "'' `�`` '
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comnlete 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 called? Yes No Unknown circle)
If yes, what department or agency? ST �AUI �p}�1' C�. Case#or report# N��
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 possible. If necessary, attach a diagram. _
Please indicate the amount you are seeking in compensation or what you �v��uld like the City to do to resolve this claim
to your satisfaction. � � �D�J. �P �
Vehicle Claims-please complete this section ❑ checl:bcx if this s;,ction does not a i
Your Vehicle: Year I qq a Make I-`E�N OR Model A ��
License Plate Number��y E�H State Mh) Color i
Registered Owner �� V l�t��s'
Driver of Vehicle H'N��E 'V�
Area Damaged �W� �ow - No �A�+�-�-c�
City Vehicle: Year Make Model �''
License Plate Number State Color �. �C�
Driver of Vehicle(City Employee's Name) �
Area Damaged
Iniurv Claims-nlease complete this section ■ check box if this �ectibt�dbes,r}oi applv
How were you injured? � � ` � ` ���—��
What part(s)of your body were injured? ' ::+ > ��J��.
Have you sought medical treatment? Yes , No Planning to Seek Tre��r��t(c�rcl�) ,
When did you receive treatment? J,` �'i,�`(prcavic�e�tl�te(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))
i�tame oi your Ernployer:
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.
Submitting a false claim can result in prosecution. Date form was completed
� ( � ELU ��-r
rrint
the Name of the Person who Completed this Form: ee � �I ��� �I�I'�
�-__
Signature of Person Making the Claim:
Revised February 2011
♦
i ���
"Letter of description as to what happened and why"
� On May 27, 2014, I was at work and received a phone call from my roommate stating that my Honda
Accord is missing from the space where it was parked.
I called Saint Paul police to report my missing car. Given them my license plate number 064ERH,she
told me that my car is not stolen, it has been towed by the city of Saint Paul police for scofflaw. I
explained to her that the tickets do not belong to me and I am the new owner of the Honda Accord. She
gave me the phone number to where my car was impounded at and I can explain to them that the
tickets does not belong to me and I can get my car back.
I called the impound lot to confirmed of my car and explain that the tickets does not belong to me and I
want my car back. She explained to me that if I want my car back I need to get a letter from the district
court violations bureau stating that those tickets on the license plate 064ERH does not belong to me and
she will release my car to me with proper ID's. � �
I went to the district court on May 28, 2014 on 15 W Kellogg Blvd St Paul, MN 55102, and got my letter
to release my car to me and I asked her about the charges of towing and storage. She told me that I will
have to pay for it. I told her that I was not happy to hear that and the towing of my car of those
tickets does not belong to me and has nothing against me.She explained to me that I can file a
claim against the city for wrongful.
I
� ����
STAT E O F M I N N E S OTA c�o;�..,
DISTRICT COURT :.,� �•Q,
SECOND JUDICIAL DISTRICT
Criminal &Traffic Division ��
Violations Bureau St: Paui Branch �j., -- -
Room 130 Courthouse, St. Paul, Minnesota 55102
(651) 266-9202 ��i��
SUSAN M. BOWNES
Manager
May 28, 2014
St. Paul Police Impound Lot
830 Barge Channel Rd.
St. Paul, MN
Re: MN Plate 064ERH
To Impound Lot Staff:
The above name vehicle was towed for scofflaw on May 27, 2014. All of the citations that
qualified this vehicle for scofflaw status were issued to it when the vehicle was owned by its
previous owner. The Court will not enforce collection of fines and fees on citations issued to a
previous owner. The current owner plans to secure new plates for the vehicle once he removes
it from the impound lot.
Please call me at 651-266-8101 if you have any questions.
Sincerely,
/ �/p�,
%���'1/► J
Susan Bownes .
. �`�� ��- . ,��: {� �-�:`��.:�.
� .':�;�
, .
- ��;� .
Saint Paul Police lm�ound Lot, 830 Barg� Channei P.oad, Vehicle Release Form � ��c�
Make: 99 HONDA License#: 064ERH CN: 14103442 Invoice#: 150r78
Date/Time Released: 05/28/2014 16:38 Tow Charge: $ 60.00
Released to: TOTO Storage Charge: $ 15.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: BECKY Tax: (7.625%) $ 10.68
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 165.68
I will check the vehicle for damage or any other problems that
may have occurred while this vehicie was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowiedge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 165.68
on this form prior to leaving the impound lot
Damage and/or cther probfem�
Police Report made: Yes_ No_ IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature siz000
, . _�,'�jy�`._','Si:t '� f-�'.;,'`.
� : 2u��
� ,,;,�.c;���
. :FR ;t � . _ .
, ,,-
� �.
� �..;� �z::_. �
�-- �� ---� '�—'x — V����
_ :.�. :p x ^;
. — � cv � ��x _
— _ �' �- _�
'- � -- >c .-.a
'" � x ��
�e�
O� X . ,. �
— m X O�—'
•—�G��� X O C �
�' X 1��� �Ji�^ .
L L6 —i W�
v - o�s E
? ",�. s.¢. �
� U CO� 91�� CPDWTi
/AS �r]'.� •CDC
� �.� u ��
. a o � °e i. T� _
-. - �, o i-- ^� _. ,
on c,zc�—
o � .,;� � a �� Do
a- ncn—=
. �- - � � =u+`—`o .
- z -c i-- n�r rf .
� +s� a mrr
_ Z � ��y
�7 C� �N G
C
c �n
� 2. E
"" Fa "
.G'T=
O - F--� G!:
t Ci.i G =
—�F�� C-.
p_a �_ a
GS h. G.."s �G
Ci-—v O'.� f3—
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 99 HONDA License#: 064ERH CN: 14103442 Invoice#: 150778
Date/Time Released: 05/28/2014 16:38 Tow Charge: $ 60.00
___ _ _
Released to: TO-f0 Storage Charge: $ 15.00
Paid by: CREDIT CARD Admin Charge� $ 80.00
Released by: BECKY Tax: (7.625%) $ 10.68
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 165.68
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 andlor any other problems to the Impound Lot staff Total Charges: $ 165.68
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 P�OBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature siz000
, � - .,G_'
,� :
�; , �
.�( ;�� �'ti!l� Y.•�� i
i S t
. . ' � . , ..,� .. :.�. �V1� '
(:
. ' � ^� \ ,f.;�j yr_,-;
� L
� 1�. .` - � �:.<< ;T
` `", tv�r�.�:;r.�--�"r'
;--,�.J�