Horbach �E(������.�
MAY 0 ? 2 n��
NOTICE OF CLAIM FORM to the City of Saint Paul, �t��
�_ ..�
Minnesota State Statute 466.05 states that"...�ry person...who claims dcvnages from mry municipality...shall cnuse to be presented to the
governing body of the municipality witiun 180 days after the aUeged loss or injury u ducovered a notice stating the time,place,and
ci�rumstances thereof,a�rd the amount of canpe�ation or other relief demanded"
Please complete this form in its entirety by clesdy typimg or printing your answer to each question. If more space is
nceded,attach additional sheets. Please note that you v►�l not be c�tacted by te�eQhone to cla�afy answers,so provide as
much information as nec�ary to explain your daim,and the nmount of compensation being reqnested. You w�71 re�ive a
written aclrnowledgement once your form ffi received. The process can take up to ten weeks or longer depending on the
natare of yotff claim This form mnst be s�igned,and both pages completed. If something dces not apply,wrlte`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102
First Name l• �O Middle Initial � Last Name ��-b�G� .
Company or Business Name
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address_ 1 I S� r,S'� G`�-� Ll.j � �"�lL u� S�`.
City � �"0•�-U L. State ✓� �'`�' Tap Code �.S �� c1
Daytime Phone(6�l�3%-Zys3 Cell Phone(bTl)�����Evening Telephone(�i _`��'►.�"v�. I
Date of Accidend Injury ar Date Discovered 6�'✓�'0 rN�i Time ��P� II
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 andlor respons�ble for your damages. 1�+2�-i� -�i�k/.
O�- Cs2�v S'��OfzC �,,c�r+� 1�/�i c �'L �'N V l'�-,.�-c/u�r�%,7 ���9-t �_�
r ,
M UJ� �~'
�'�l
U C� '1/ \ /'L Q �, � S+
� � � 2�c$V� �.. �y
�o•v � ,� g.✓c� . c � 4,•I -¢-.tin.,Q..- A,- z d-�/�
��Zc bt � W� n-s
Please check the box(es)that most closely represent tl�e 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 pmperty
�Othe�'tYPe of PI'oPertY damage-please specify �n.��S /L� -�v /i .¢uc, 5'�u r.•.gc Qi4��/�.
- ��► A-�1 c1 ��- /,I-'� 2 c� � ~�- 'L � n/E
In order to process your claim vou need to include cooies of ail aanlicable do�vments.
For 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 retiuned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your ciaim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$SOQ.00;or tl�xtual bills and/�receip�ss for the repairs
O Towing claims:legible copies of any ticket issued and a copy of the impound lot�eipt
�Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or recei�s for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
�Photographs are alway welcome to�cument and support your claim but will not be retumed. 6� �s�£ W'�
�c�-�.y ���.Y
Pa�e 1 of 2-Please complete and retarn both pages of G7aim Form
Failure to complete and return both page.s w71 result in d�ay in the handling of your claim.
All Claims—plea�e oomdete this seMion
Were there witnesses to the incident? Yes No Unknown (circle)
Provi the names, �r�es and tel numbers• ��'L -- �4� �..
-�iC�ll�ct� 'F" �G_ I�v,S 1�f4 � �N ,021�}�i Srya�, �tne �he � S''f'. I !0 70a' I a3�
Were the police or law enforcement called? Yes No Unl�own (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 ar facility,
closest landcnark,etc. Please be as�tailed as possible. If necessary,attach a diagram.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your sfaction. ' O Q V D � 5z►i-'h-��--F �'F �
��,o ��.. t-/ �
�'ehick Claims—nlease oomolete this secti� ❑check box if this section dces not a,pplv
Your Vehick: Year Make Mockl
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
Ininrv Cla�s—nlease comolete tLis section [7d"check boz if this section does not app�
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)) ,
Nam�e 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. I
Address Telephone
Check here if you are attaching more pages to this daim form. Number�additional pages�.
By signing this form,,you are staaing dwt all informalion you have prnvided is true and correct to the best
of your knowledge. Ilnsigned forms will not be processed
Submitting a falsa claim can nsult in pmsccution. Date form was completed
Print the Name af the Person who C�pleted f'o •2.6 A�
Signat�re of Person Maldng the Claim•
Revised February 2011
TO WHOM THIS MAY CONCERN.
This letter is in regards to a properiy problem that I have had since the installment of city
water and sewer. I had the City Engineer out to my property three years ago and he stated
that he would contact me in regazds to my problem. Since that time I have not heard from
this fellow,nor has anyone contacted me.
I was instructed to e mail pictures of my property when the problem occurred and I
complied. Enclosed you will find pictures of my problems. The winter pictures were sent
to City Engineer. The rain pictures are the rain downpour of the 4�'of July this
year.
_ _�
::� """„��,.-;_,.
� _�..� ��� �- . �.:��•
.� � rr F�
,
� � k� �
.,
�Y_.y ... 4�,, ,
- . >;.. , ,. . . .
.:_ _ _. '�-_., � .� .,
.� _; . .- ,- ._ .,_ _ '-. .. _ „ ._ �,. .. .
-
�
...— � _ . .�; .
- _ . _ . -:�... . . - . � �.
- _ ' �
�` C
_ ... . ,..., , .. . �
_ � ia : � I I
�r ""'` `�z �� �
r . zwy � �� � � t } 4 �•a
. _a + -... ��, . � � 1._ �...
.. . � f.. � . � a�� ��.� �i
• � � ' ° i�� ����` � I
.0 .. . � .*: �.
� a �;
..
a _
�� .�„ 't �,��'.
� . ... -.�-Y�... ..:..'�
fy
. '
�'^' ��i
�V:w �\ �J
�, y� ... ��.+„-r'r�� p r;� &} ip�. �� '.�°
� ��...tdM�.�'�:. �� ` 1Y . . ...a.�4+s.au�vv. �—��y� F�..+p� x'.n�fA"4 �1�.'��.'�i'_-µa
+»iKr.
�. . a
�- ^�i, a
.�
,C"'�. ��4 :'_ � -��.:F .._ "' ... "':
. -�- .. .... -'tr yK
, ,�� .. _- . � - � �-�
�..: �,;;�� ..
,�,
�.: - ' _ ��_,�.' �'-�",... . ,. _ I a�$�
,- ;F�F .�
�� ar .�-�`
,. �
..�- � _ �� �u,�.
"� >� °` � q, "
- �
J
' '.,
�� �, , , . �
- �'�- =*+�;
�: .
��:
�° " � � � 1� ' � ` �'.
`�,t �� , .:' t
��� �,;� �--:� :
. r.'�. S 4 . .
t„ 'f � �I�
. �� , . �,.�„� , '�`� _ � . � � . ��.�:�. "'�. '+.
... ' �. . :�. .
... . . . ._ ..<i,.�q�M!!tl
� i� 't '� -� �� ,: ��
�
, . y zv.:y ��
�.
� �; �
y . :i-.' " ;�. {s.
�..�.,` y ���'
, . ... �` .. �!'pa"
y,
,.., , _ .
�� � +"� ___ �� �j r� y�'
> _ ;
� � � _ k_�.. _ - .,.
�
Q . ,._...,.�.� � „�.�. _,
_ � .,
,.„. ._. .
°--- +w+'. .,� . ` �tM'9�+--r :..ms
:� �'�`'"'_ �,�, _ . � „ .'"1
. � �� _
g��� ' � . . . �\.
.n�'�. _ _� .
.w^ ,!� � �tlb"�"'�`
. -� �._
�;.; -„
.w�" �,e ,
�. �w
w
S
,5�� _ M�'•
�Y s t.
__' p y K �_ <[ � �'
4� ...
, - . . � . ,- . . - ._�.:
..�l'a,. .. `^ a.f.�T�v _-.. ...�� �\.. . .y�. .:. ', .. ,.
a ; �
�� , �:._, .... ...
.. �.
�.
.
. .,..-. ... , ., � ._
. _... ._:, = v...... ... .
�_, .. ,.,.. . ._ � '.
�� �.
,\
' L
R H{;
�6,�r �� 1�� e� �� . . �a�y. ��u
,a�rk . {x . ,�,�, �!�' "L4
� �y9� �°�t�' ::
�� �. . 5�� '-.%� ���� .,�'�'., c� � �
' . V. �� • -:�i ; � u¢ .�'w`
�� J�
. .. . � � d! ` ��� � �� ��..
/ —r - , ~ __ �' l�� - F '�-^,���� ����'
. �
� .
.. : . .. . �.T, .4 . '..
:..
. . � _" _ . . R, .. , .
� ,� �.. . ... e �� ' � �g%�.
:�r - .. . �5�.�y - E � -_
. :+.- , - .. . .�.. � y,�r�'�_
. ' . � . . �� »g, . - �
- '� � �
:.�.x � *�� _ " ;`,:= 3Et4-. ����$ .�\ - `� ^�
° — � ' "r
_.. .__.:____ .____....- . . . � • . . _.. . . - I
. _
_. _ .. ._ -� r, . , .. .. ,,
. ..�� . , . . 0 4�
� � - •� ' �- 4. �:
��
'_ L
'�.�.,�• .�.3 . }* '
'� ,�* ..� ( : +s'� � .a�:
/6,� �. �"�• y,4�,�' �`�!'.. ,I` '�
. , q'*� ' ` � `, ,.�, _
.v $ � �
-°' - t.� . � � � 4
�� 'AF�-. '�l` - .�^ �kT�d T
�'b`A� . � S .. . , .Y ... ., � _ . . " ".,a..... .4�� � ...
� g .. .. ' 4�. y �.` t/" z, ..
'� i�, � `1 . �y�� . .. . ..
.� . �'. F, ry� 1� � .
�l���'�C . , � � � .' . . . �'\����� �.��, �� 'c � , .
. . �,,. � .a i s
. . �.� _ � . '.� E .w ._ - �_ � .
� �
a. ' ' - r��i � � .
Y�
.. - . . m .. �3� �� � . � . :�
�
�.�� i���. . w�r �� � �' . . ..
;e� .°:' �t,Ft� �� s."3'"'
tw.. ,. .�„a... _ . .: �� �.� � =�`y+rr-r a".r� �^
��� �� `���� � �
wi� -
� � _,�._ _ �
t� :� - _ ���, _.__ �, _ „.�
. . ��_
_- _e ..
, � � __ : �..
_. ., _
� ��;��� �
.. :,��;..,, ..,,,,� -'�—..,,�
�. �
� � � `� � ,r{ ��. �..
�� �`"'-i�lf r� ��,�� -,.
., '.: , �,
�� ��
° �, ° .
£ �
s�`� � �i t�F ,. � �t.
�'�.� �;�:: T� �' ,,, .,�
��
�r;.
. i:
��
�� �, �-;
:�� .
_�,
4
1
���
. �� �
��jf I
� �
` '�
�
_ - � `,�,
� � �' `
_ � 1
. .
��.
4 �
� t
��
� � `
r..
{ � �
� _ � ,.. .. ._ . r. . ��• �i �
i . - .r . � - ' - �. .._ .
' I
_. " 7r:
�"' � �.
�.r
� l �
�_
r
_ s _�-
. . � . . . ��`" . J' . •
.. .. . . � ' '^i✓ ..'%,
. . ' ' ` . . ' -�f,.".�.' . _ ..
, �
. _ _ . `. ._ ,t` - . _ .
. :,��4.i:. � .. �� _
r
- i . ._ _ .. . _. ` � �
. .- _. ......_,....__... _ ` ' � '-
�. r` fI �
.5
��&:.,
_ '+L'
r'
.. { � ,'.�..:�..
F
I have invested in a sprinkler system, and I ha.ve an up to date drainage field, my septic
system has been updated and functions properly. Most of the trees on my property are
dead or dying,due to the water problem. I actually have one tree that is over 4 feet
around that has a two foot hole through the bottom and is ready to crash.
Why is it that I must pay for a sewer system that is a determent to my property?I was
also under the assumption that this improvement enhanced our property value. I have a
solution. Fix the road problem. This was proposed once and was suppose to have been
repaired. This last rainfall picture is the fourth of July this year, Does this look as if any
repairs were done. i
Now comes the real issue,what about the damage to my property? Who pays for the
removal of these trees? Who pays for the new grass and the severe damage to some of my
property?What about my septic system?Could this problem shorten the life of my
septic? I have a solution. Hook up to the new sewer system, free of charge. I do not know
if it is permissible to sue the City and I do not have the resources to do so, but I think an
injustice has been done and I want some closure to this problem.
I rather doubt that I have made an unusual request. Hooking up to the new sewer system
and installing some type of curb would not only benefit myself,but would be a goodwill
gesiure towards any further action. A more costly course of action would be to remove
the problem trees, and install a new drain field,which,is no longer an option.
I will await some sort of solution to my request. I realize that the City does not act in a
timely fashion however; I have waited since you put this road in to have closure.
Thanks for your time.
See enclosures:
Leo Horbach
651-731-2453