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NOTICE OF CLAIM FORM to the City �-��}��p.�aul, Minnesota
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 municipality within I80 days after the a[leged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other re[ief 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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. 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 .-�k-F-����(�, Middle Initial� Last Name�m�,�.
Company or Business Name, if applicable
Street Address � S �
City , State ��,� Zip Code�� ��
Daytime Telephone (�) � — � �} Evening Telephone ��C�-1�V�Q_
Date of Accident/ Injury or Date Discovered � I ��� ���., Time � � ��dU am pm ircle)
Please state, in detail, what occurred, 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.
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Pl se check the�ox(es t ely r��sent �easo for�mp is`�r��f�'"'m (��� I I
❑ Vehicle was dama ed in an accid�
g O Vehicle was damaged dun�ig a tow ���
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow�},�m
�Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property I a ���
❑ Other type of property damage-please specify
❑ Other type of injury-please specify
❑ Other type not listed-please specify
In order to process your claim you need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claim form, but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs !
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates, detailed list of damaged items
O Injury claims: medical bills, receipts
O Photogaphs can be provided but will not be returned.
Page 1 of 2 - Please comptete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
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Notice of Claim Form, City of Saint Paul, page two
All Claims -please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
If yes, please provide their names, addresses and telephone num .
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Were the police or law enforcement c lled� s No Unknown (circle)
If yes, what department or agency? �„�� � �_ Case# or repo
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park
or facility,sclosest landma\k, etc. lease be as d�ailed as possibl�If helpful, attach a diagram.
. �� �� ���.�
Please indicate the amount you are seeking m compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction.
Vehicle Claims- lease com lete this section ❑ c eck box if this section does not a 1
Your Vehicle: Year-���l.r�Make Model C.
License Plate Number State � Color (�1,�
Registered Owner
Driver of Vehicle .a- '
Area Damaged ;
City Vehicle: Year e Model �
License Plate Number State Color '
Driver of Vehicle (City Employee's Name) '
Area Damaged
i
Iniurv Claims- please complete this section ❑ 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�. ,
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 wil/ not be processed Submitting a false claim can result in prosecution. � �
Print the Name of the Person who Completed is rm:
Signature of Person Making the Claim:
Date form was completed � ��(�� _ Revised April 2007
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DEPARTMENT OF POLICE
Thomas E.Smith,Chief of Police
CITY OF SAINT PAUL 367 Grove Street Telephone:651-292-6005
Christopher B.Coleman,Mayor St.Paul,Minnesota 55101 Facsimile:651-266-5711
CERTIFIED NOTIFICATION LETTER
STATE OF MINNESOTA
RAMSEY COUNTY
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�Date Notified: 8/1/2012 C.N: 12180074 Date Towed: 7/30/2012
�Tow Location: AVON/LINCOLN V.I.N.: 1HGEM22593L068185
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Year and Make: 03 HONDA License No: 177BRJ State: MN
�
�Owner: Bement, Andrea
�
r— 556 Orleans St
St Paul Mn 55107
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�Invoice: 139092 '
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The above listed vehicle, in which you have a property interest as the owner/lien holder, has been impounded by
the Saint Paul Police Department, in accordance with City Legislative Code Chapters 161, 162 and 163, ,
Minnesota Statute 168B.04, or other applicable law. This vehicle was towed to and is being held at the Police !
Impound Lot, 830 Bar�e Channel Road, St. Paul, Minnesota 55107
aimir�Vehicle
Under Minnesota Statutes 168B.051, 168B.07, & 168B.08, you have the right to reclaim the vehicle. Also
pursuant to the above statutes, you may have the right to reclaim property from the vehicle. Failure to reclaim I
the vehicle and/or its contents within the appropriate time allowed and under the conditions set forth in the '
governing statutes constitutes a waiver of all right, title, and interest in the vehiclg and its content. Please see
the attached information for pertinent statute language.
If claimed, the vehicle and/or its contents will be released to you upon satisfactory evidence of ownership,
insurance and payment of all towing, administrative fees, storage fees and tax.
If you do not claim the vehicle and/or its contents within 15 days after legal notice to the owner, it is considered
a waiver by you of all right, title, and interest in the vehicle and/or its contents and consent to the transfer of title
to and disposal or sale of the vehicle and/or its contents under Minn. Stat. 168B.08. The City will dispose or sell
any unclaimed vehicle and/or contents. Per Minn. Stat.§ 168B.051 Subd. 1 & la.
AA-ADA-EEO Employer
If the vehicle is sold, the City shall first reimburse itself from the sale proceeds for the cost of towing,
preserving and storing the vehicle, and all administrative, notice and publication, costs incurred. Any
remainder from the proceeds shall be held pursuant to Minnesota Statute 168B.08, Subd.3 for the owner
of the vehicle or entitled lien holder for 90 days. If there has been no claim on the remainder of the
proceeds within 90 days after the vehicle sale, it shall be deposited in the City treasury.
Contents in Vehicle
If you are a vehicle owner and can provide to the impound lot operator documentation from a government or
nonprofit agency or legal aid office that you are homeless, receive relief based on need, are eligible for legal aid
services, or have a household income at or below 50 percent of state median income, you have the
unencumbered right to retrieve loose personal property without charge. All other rules of the impound lot still are in
effect,party must be registered owner of the vehicle. Please see the attached information for pertinent Omnibus bill
language.
Please refer to our departmenYs website for additional information on our Impound lot with links to the full text
statutes referenced in this letter. Our Website is http•�`/www stpaul �ov/index.as�x?NID=461 . You will also
find in our impound lot section some questions frequently asked of our impound lot staff. For further
information, call 651-292-6005.
Sincerely,
Thomas Smith Bret Smith
CHIEF OF POLICE Impound Lot Manager
I
AA-ADA-EEO Employer
Minnesota Statutes
168B.051 SALE; WAITING PERIODS.
Subdivision 1.Sale after 15 days.
An impounded vehicle is eligible for disposal or sale under section 168B.08, 15 days after notice to the owner, if the
vehicle is determined to be:
(1) a junk vehicle, except that it may have a valid, current registration plate and still be eligible for disposal or sale under
this subdivision; or
(2) an abandoned vehicle.
Subd. la.Sale 15 days after notice by certified mail.
An unauthorized vehicle impounded by the city of Minneapolis or by the city of St. Paul is eligible for disposal or sale
under section 16fiB.08, 15 days after notice is sent by certified mail, return receipt requested, to the registered owner, if
any, of the unauthorized vehicle and to all readily identifiable lienholders of record. *If, before the expiration of the 15-day
period following notice of taking, the registered owner or lienholder of record delivers to the impound lot operator a written
statement of intent to reclaim the vehicle, the vehicle is not eligible for disposal or sale until 45 days after the notice of
�taking, if the owner or lienholder has not reclaimed under section 16RB.07. Notwithstanding section 168B.06, subdivision
�
°3, a second notice shall not be required.
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�168B.07 RIGHT TO RECLAIM.
�Subdivision 1.Payment of charges.
�The owner or any lienholder of an impounded vehicle shall have a right to reclaim such vehicle from the unit of
�government or impound lot operator taking it into custody upon payment of all towing and storage charges resulting from
�taking the vehicle into custody within 15 or 45 days, as applicable under section 16�sB.051, subdivision i, la, or 2, after the
date of the notice required by section 1fi8B.OF.
�
�Subd. 2.Lienholder.
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�Nothing in sections 168B.01 to 168B.101 shall be construed to impair any lien of a garagekeeper under the laws of this
state, or the right of a lienholder to foreclose. For the purposes of this section "garagekeeper" is an operator of a parking
place or establishment, an operator of a motor vehicle storage facility, or an operator of an establishment for the servicing,
repair, or maintenance of motor vehicles.
Subd. 3.Retrieval of contents.
(a) For purposes of this subdivision:
(1) "contents" does not include any permanently affixed mechanical or nonmechanical automobile parts; automobile
body parts; or automobile accessories, including audio or video players; and
(2) "relief based on need" includes, but is not limited to, receipt of MFIP and Diversionary Work Program, medical
assistance, general assistance, general assistance medical care, emergency general assistance, Minnesota supplemental aid,
MSA-emergency assistance, MinnesotaCare, Supplemental Security Income, energy assistance, emergency assistance, food
stamps, eamed income tax credit, or Minnesota working family tax credit.
(b) A unit of government or impound lot operator shall establish reasonable procedures for retrieval of vehicle contents, and
may establish reasonable procedures to protect the safety and security of the impound lot and its personnel.
(c) At any time before the expiration of the waiting periods provided in section 168B.051, a registered owner who provides
documentation from a government or nonprofit agency or legal aid office that the registered owner is homeless, receives
relief based on need, or is eligible for legal aid services, has the unencumbered right to retrieve any and all contents without
charge and regardless of whether the registered owner pays incuned charges or fees, transfers title, or reclaims the vehicle.
AA-ADA-EEO Employer
Subd. 4.Waiver of rights.
The failure of the registered owner or lienholders to exercise the right to reclaim the vehicle before the expiration of the
waiting periods provided under section 168B.051 constitutes a waiver of all right, title, and interest in the vehicle and a
consent to the transfer of title to, and disposal or sale of, the vehicle under section 168B.08. The failure of the registered
owner to exercise the right provided under subdivision 3 constitutes a waiver of all right, title, and interest in the contents
and a consent to the transfer of title to, and disposal or sale of, the contents under section 168B.08.
168B.08 DISPOSITION BY IMPOUND LOT.
Subdivision 1.Auction or sale.
(a) If an abandoned or unauthorized vehicle taken into custody by a unit of government or any impound lot is not reclaimed
under section 168B.07, subdivision 1, it may be disposed of or sold at auction or sale when eligible pursuant to sections
1b8B.06 and 168B.07. If the contents of an abandoned or unauthorized vehicle taken into custody by a unit of govemment
or any impound lot is not reclaimed under section 168B.07, subdivision 3, it may be disposed of or sold at auction or sale
when eligible pursuant to sections 168B.06 and 168B.07.
(b) The purchaser shall be given a receipt in a form prescribed by the registrar of motor vehicles which shall be sufficient
title to dispose �f the vehiele. The receipt shall also entitle the purchaser to register the vehicle and receive a certificate of
title, free and clear of all liens and claims of ownership. Before such a vehicle is issued a new certificate of title it must
receive a motor vehicle safety check.
Subd. 2.Unsold vehicle.
Abandoned or junk vehicles not sold by units of government or public impound lots pursuant to subdivision 1 shall be
disposed of in accordance with section 16bB.09.
Subd. 3.Sale proceeds; public entities.
From the proceeds of a sale under this section by a unit of government or public impound lot of an abandoned or
unauthorized motor vehicle, the unit of government shall reimburse itself for the cost of towing, preserving and storing the
vehicle, and all administrative, notice and publication costs incurred in handling the vehicle pursuant to sections 168B.01 to
1b8B.101. Any remainder from the proceeds of a sale shall be held for the owner of the vehicle or entitled lienholder for 90
days and then shall be deposited in the treasury of the unit of govemment.
Minnesota Transportation Omnibus Bill passed May 16,2008.This law now allows people that are indigent to remove their
loose personal property from the vehicle without charge.
The person claiming"Indigent Status"must have one the following:
1.A letter from:
A.Official Government Agency(for example: County,State,Federal,Local)
B.Non-Profit Agency(for example:Dorothy Day Center,Dakota County Women's Center,Wilder Foundation)
C. Legal Aide Office(for example: Southern Minnesota Legal Aide Service)
2. This letter must state the persons:Full name,and one of the following reasons below to receive"Indigent Status".
1.The person is homeless
2.The person receives relief from one or more of the following:MFIP and Diversionary Program,medical
assistance,general assistance,general assistance medical care,emergency general assistance,Minnesota
supplemental aid,MSA-emergency assistance,Minnesota Care, Supplemental Security Income,energy
assistance,emergency assistance,Food Stamps,earned income tax credit,or Minnesota working family tax credit.
3. The person is eligible for legal aide services.
4.Household income is at or below 50%of the state median income.
If the letter does not have the person's name and does not meet any of the requirements(A,B,C or 1,2,3,or 4)they DO NOT qualify
for indigent status. All other rules of the impound lot still are in effect,party must be registered owner of the vehicle.
AA-ADA-EEO Employer
Saint Paul Police Impound Lot, 830 Barge Channei Road, Vehicle Release Form
Make:03 HONDA License#: 1776RJ CN: 12183074 Invoice#: 139092
DatelTime Released: 08/01/2012 17:59 Tow Charge: $ 54.50
Released to: TOTO Storage Charge: $ 30.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: ELISE Tax: (7.625%) $ 1026
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 174.76
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 and/or any other problems to the Impound Lot staff Total Charges: $ 174.76
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 LEAVING THE LOT
Signature 5i2000
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