Sayre-Homcomb ����!�;�C�
DEC 2 ? 2012
P,��f 1J^r M¢�'�.��l�1,
NOTICE OF CLAIM FORM to the City of Saint Paul, 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 180 days after the alleged loss or injury is discavered 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 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 CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name��-�q, Middle Initial L Last Name
Company or Business Name
Are You an Insurance Company? Yes No If Yes,C1aim Number?
StreetAddress 1� ��1��_�l V_ ,
City ��,• �� State�IV Zip Code C�� I
Daytime Phone(�)�`��ell Phone(�)1�-��Evening Telephone(_) -
Date of Accidend Injury or Date Discovered �Z+ ��~Z��Z Time�_�/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 em loyees e involved and/or responsible for you damages.
U A S
Q Y
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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
G]'1VI�y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all applicable 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 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 and/or receipts for the repairs
�wing 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 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—please comulete 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 � Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersectio name of park or facility,
closest lOand ark,etc. lease be as det � ed as ossible. If necess y attac}�a diagram. �1(� Y101�
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Please indicate the am unt yo .are see ng in compensation or what you would like the City to do to resolve this claim
to your s tisfaction.�� —�1��� ��I1111Y1 Olf1C� r QI m�VCS'P,YY1`�ir'1�' UF'
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Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number {� State�Color �lV�,1"��
Registered Owner 01 Y�C-
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—please complete this section �"check box if this section does not apvlv
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
L7 C:heck 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�'�� .r Z"JU1, l.U�Z
Print the Name of the Person who Completed this Form: ��NI' �� `a���e���`�.o�,b
Signature of Person Making the Claim:
Revised February 20ll
Saint Paul Police trnpound Lot, 830 Barge Ch�nnel Road, Vehicie Release Form
Make: 99 OLDSMOBILE License#: 068HMM CN: 12288997 Invoice#: 17988
Date/'Time Released: 12J11/2012 18:45 7ow Charge: ` $'123.95
` Released to:TOTO Storage Charge: $. 15.00
Paid by: CASH Admin Charge: $' 80.00
Released by: GRETCHEN Tax: (7.625%) ` $ 15.55
I,the undersigned,have recovered the vehicle described above.• SubtotaL• $ 234.50
I wiil check the vehicle#ot damage or any other prbblems that
` may have occurretl while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge'"1 will report `
damage and/or any other;probiems to the Impound Lot staff Total Charges $ 234.50
' on this form prior ta leaving the impound lot. ,
� �� Damage and/or ofher 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 , si2000
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' * $T. PAUL
STA`fE OF'MINNESOTA-I�AMSEY DISTRIGT COUR1` �(��II�`��I�,�I ,�I�I� �I `�II�"� ,I�� I�( � � "
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The undersigned,being duly swnr�a,.Lpon hismer path deposes anci says: �
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* $ $'' $ 7"'�4 � 7 $ 6 *
Date of�ff�n�e �� � �,� � �� Time of f3ifense �� �
Plate �
Veh.Li�ense Nb.��,�, �'���� Year �Y� State__�'� AAske �,..`�'�t ',� Style � � Golor' .4��
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Location of Offense. �r=`�*.� �.�'`�� �r � �"�;.� � ��'"�1..s( � ;��,' �,: ��:�
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VIOLATION:�� .� SNOW E�IEaGENCY St.p�u#�ra�lr�n�e 1�1.03 ���� �i���' ,.�� ,
` (Amount inclutl�es mandatory state suK�h�rg�s of$1�;i1�) i <
CN ����``���
Citing ��• Officer � �
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C7fficer ��,��-*> Numbar pepi. �.,,� '
�'osted Night plaw ❑I�ay Ptow ❑Plowed in(Windrow) �agged Befbre Plaw CI Dro�H Qif i
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OFFfCER'S NOTES ' ;. , �
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` Citafion aart b�pald a�t th�Impound Lot:C�lease r+�d the bAC�k of th�cltation for paymeM instructions,
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DEPARTMENT OF PUBLIC WORKS
Rich Lallier, Director
CITY OF SAINT PAUL Kevin t�'elson,P.E.Street Maintenance Engineer
Christopl:er B. Coleman, Mayor 873 Narth Dale Street Telephone: 651-266-9700
Saint Paul,.� 55103 Facsimile: 651-266-9736
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December 14, 2012
Samantha Sayre-Holcomb __ _ _ _ __ _ _ __
6301 Lyndale Ave. S. #103
Richfield, MN 55423
Re: Vehicle License #068HMM
Dear Ms. Sayre-Holcomb:
This letter is to express our sincere apology for the inconvenience caused during the recent snow emergency
where you were towed andlor ticketed.
The Department of Public Works needed to make snow emergency plow route changes in your area due to the
light rail construction. Due to a gap in notification, you were not aware of these changes when we declared the
December 9th snow emergency.
For this snow event, due to the lack of communication regarding these route changes, the ticket will be forgiven
and any towing and impound lot fees will be refunded to you. Please contact us at 651-266-9800 to arrange for
reimbursement.
For all future snow emergencies, you should note that the day plow/night plow rules will be followed and no
additional allowances will be made to ticket fees and/or towing charges.
Again, please accept our apology for the inconvenience this has caused during this snow emergency.
Sincerely, , � - " ��-j�=�
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1�'��n! ����1/ ..
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Kevin Nelson
Street Maintenance Manager
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