Willard, Amy �Z���i`lED
� JUL 14 2014
NOTICE OF CLAIM FORM to the City of Saii�I��Yu�r��sota
Minnesota State Statute 466.05 states that"...every person...who claims damages from 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 ciearly 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 dces not appiy,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 il Middle Initial Last Name ����� I��° �`
�
Company or Business Name
Are You an Insurance Company? Yes/(No If Yes,Claim Number?
Street Address �7�� �:C�T�1 �'�' /�-�" �
City �- ����'� State ���" Zip Code /�
r�1�' �xi�<<<-'
Daytime Phone(�)jt� - `�Cell Phone( ) � - Evening Telephone(_) -
Date of Accidend Injury or D�te D_�iscovered 3`1��lG( 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 Cit,y of Saint Paul or its employees are involved and/or responsible for your damages.
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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 vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
O Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou nee�to include copies of all apnlicable 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 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
C�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—nlease comulete this section
Were there wimesses to the incident? � No nknown (circle)
Provide their names,addresses and telephone numbers: � r 7 1
�- �� � �,UK
,�
Were the police or law enforcement called? Yes CNo; 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 pazk or facility,
cl sest landmark,etc. Please be as detailed as possible. If necessary attach a diagram.
�P I'� �,I l�v'-Lt�� l�'2 Gc.�" 1�1z�l �
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. � "cf;L ���,.i � � � %i11�iL:�°' i�c� �' ti� :" 11� C"Lu"
Q•�=l�r {-�w � 2i �.50
Vehicle Claims—ulease comnlete this section �check box if this section does not apQlv
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 �heck 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
Wt�n did you miss work? — ---- - - - (provide date(�)j
Name of your Employer:
Address Telephone
�7 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 �����
Print the Name of the Person who Completed this Form: �v1 �/�}t �lU�C�
,
Signature of Person Making the Claim: � '` C�
Revised February 2011
On Feb 28, 2014 winter parking
restrictions went into effect and "No
� Parking" signs were posted on both
the east and west sides of Herschel
Street.
After a few weeks,the signs came
down from the east side and
remained on the west side.
,` 'Y�""��. � ��. -
.
° 's �' (These two photos are of the east side,
looking north.)
_ .,�
Even though the signs had come
down from the east side of the street,
_-- residents continued to avoid parking
on either side for quite a few days.
Then, on the evening of March 13,
five residents, including myself,
parked on the east side, after
observing cars parked there and
reasoning that parking was indeed
allowed on this side.
It was a costly mistake as all five cars
were towed during the early morning,
without warning, and the next night
an additional three cars were towed.
_ • , This was a legitimate
" misunderstanding and none of us
knowingly disobeyed the parking
restriction.
As you can see from these photos,the
east side was cleared and the signs
removed,while the west side
remained clearly posted.
This photo is of the west side,facing south,where signs were still posted.
�� Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 00 FORD License#: 159MMK CN: 14040882 Invoice#: 29645
Date/Time Released:03/15/201412:56 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: JOHN 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 c�stody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I w�ll 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 LEAVtNG THE LOT
5/2000
Signature
ST PRUL It1P(kAYI LUT
83[i BARC�CFINNEL RD
' SAINT PAIN.. MN• 551b�295d
j 651-261i-S642
� Nerchant ID: 56863tibi�4
Ter� ID: 8B173Q01i6�3t3N144c1b
S�le
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�ASiERC�D EntrY�ethod: S�i�ed
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N�i1S�14 12;�:51
Ir�v�, � R�mr Ca�; 61514B
R�w�vd: Online
c�co.n-c�Y
TFIANK YOU!
� �:
Ramsey District Court
RECEIPT
Date/Time: 4/22/2014 15:45:44
Defendant: WILLARD, SETH DANIEL Receipt No.: 2196413
Payor: SETH WILLARD Location Paid: MAPLEWOOD
I
Citations: Amount:
620900231436 17.00
Amount to Be Refunded: 0.00
Total Amount Paid: 17.00
Method of Payment: VISA
Check Number: ,
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RAMSEV DISTRTGT COURT
15 KELLOGG BLUD bl STE
SAINT PAUL� h�J. 55102
651-266-1999
1ER�IHAL ID,; 981134BB99989113643BB4
lfRCHANI q: 9589113643
MA3TERCARD
��kt�kt�M##1128 EKP;KRlKX S�IPEd
SALE
RECORU; 31 IP�U: �0�033
DAiE; Apr 22� 14 iIlf; 14�26
BATCH� 888215
AUTH:02252B
TOTAL �17.0tl
SEiH D �ILLRRU
CUSiOMER COF4
KEEP THIS COPY FOR YOUR RECORDS
_ _ _ _ _ _j
� CITATION � - :
State of Minnesota I
� ,
Citation#: , i
620900231435 -- { ?
County Name#,:' Sequential Citations_of_
- %�""•,v":✓.;'f
Identification:. �p�DL j ❑DVS Web p Photo ID ❑FP O Other
DL Number
MN ❑CDL ❑State
Name: First Middle Last Sufix
AddreSS-Street,Apt#
City State Zip �
DOB(mm/ddlyy) Height Weight Eyes Gender N �
� '
❑Juvenile Court Parent or Guardian's Name� � �
Offense. Circle One: a❑dd ess as Raee S Q �
JTR,JPO DEL Address: - � Juvenile � �
Veh Lic.Na Plate Year State Make Style ❑16+pass. Color W
��.�.9 , �. ; , � t
'�i ����1 t1 �;L 1.,, �._ t_;f ' L:�'r C�..>•�.._`' )� �1 +
Date of Offense ' rTime of Offense ' ❑AccidenUCrash y � f
, -'' ;>°�'� �-� '. ❑Pro e ❑In'u ❑Fatal , p Pedesfian �
j ❑Unsafe conditions '❑Endangering Life or Property" ❑Commercial Vehicle �
tWeather. 'Court appearance required'rf checked DOT# �
#Pounds overweight: !
Hazardous Material DO
❑Driver ❑Owner ❑Passenger O Operate .•d Parked O Booked �
Offense Location Circle On@.R�itq/Countylfownship/Other i
:�f-- !;'°,,1 3�L=i'> ):�.� Of: ;3- ti,. v't_.
Offense � Change Description Statutel0i� ❑3rd PM,M
j � ' � '' � ,c�.. j �-�:;, i�•,�;� 1 i,'� violation GM
i_� �
Offense Change Descriptio StatutelOrdinance ❑3rd PM,M
violation GM +
Offense Change Descriptio StatutelOrdinance ❑3rd PM,M `
violation GM �
Offense Change Description Statute/Ordinance ❑3rd PM,M a
violation GM �
❑Speed Minn.Stat.§169.14(subd._) mph Zone PM,M ❑3rd in 12 months �
❑No proof of Insurance Minn.Stat.§169.791(subd. ) M,GM
❑No Seat Belt Use Minn.Stat.§169.686.1(�) PM
AC Taken-AC: Test Type: ❑Refused ❑Breath ❑Blood ❑Urine j
If this is a payable citation,you must pay the amount owed or schedule an �
appearance within 30 days from the date the citation was issued.
See the back of this citation for more information.
Officer(s)Name(s) �... i Officer No(s)j � � Prosecutor �
t
Controlling Agency(CAG) How Issued Date Issued
M N062Q800 ❑ M Person ❑ Mailed I�Ceft at Scene
AgencyName: ,-;',' CN/ICR°�:j.�;;:�a v,.
Version:2013.1 ;
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DEFENDANT �