Steger ����:?���
DEC 2 � 2012
NOTICE OF CLAIM FORM to��br� �i��f 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 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 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 egplain 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 ��1� � Middle Initial � Last Name ��'c� P r
Company or Business Name
Are You an Insurance Company? Yes/�If Yes, Claim Number?
Street Address �/6 2- �� cma1—��
City �� ���,�� State "'(�'( Zip Code �S D
Daytime Phone ,-�(z Z yL-6��! Cell Phone (_) - Evening Telephone( ) -
Date of Accident/Inj ury or Date Discovered l T/ i o I I 2- Time �'Gn 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. pu. ,�,,�o „P�,�/�r
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Please c�ieck t�ie box es)that most c�oseIy represent the reason for complet�ng t is form: (�� � �F �,� �o ori�cN ,�,
❑ My vehicle was damaged in an accident ❑My vehicle was dama.ged during a tow� ��
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow�uuu��n�.�.
.�'My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property IQit s�s Sfa,�k- 4
❑ Other type of properry damage-please specify �'u"'� �"'�
❑ Other type of injury-please specify �v� 1�u���t l�o�l�
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In order to process your claim vou need to include conies of all applicable documents. C�P��
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of .�w �
your claim. Documents WILL NOT be returned and become the property of the City. You are encouragec�to keep a��y,�o�
copy for yourself before submitting your claim form. �s• �i.?
O Properiy damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceedswai ���
$500.00; or the actual bills and/or receipts for the"repairs oC �,;j;�F �
�8f Towing claims: legible copies of any ticket i$sued and a copy of the impound lot receipt H�.�� W as y����
O Other property damage claims: two repair es�imates if the damage exceeds $500.00; or the actual bills ,k�
and/or receipts for the repairs; detailed list of damaged items �Ir {C ��
vC � '�
O Injury claims: medical bills,receipts F� �,�.�� �� �
O Photographs are always welcome to document and support your claim but will not be returned. �r�� �
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� Page 1 of 2-Please complete and return both pages of Claim Form `� � t
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-ulease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: �q�� %fr(��lp S/ - 20� � � i `,�'�'
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,intersection,name of park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. //(�Z ��,,,s'
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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. `/�%. 5D �t ;c��a uic.,� d I A� . �' r�0 � ,� �- ��, I,p �.�-„r�
���b- r�..� � �����l���i� c��t�h� �#s , 7� ti Z� z��qze y � ��gz� 7
Vehicle Claims-nlease comnlete this section ❑ check box if this section does not applv
Your Vehicle: Year Zoo'� Make I��w�1-rn Model I��V � V��„rje Z(����
�) License Plate Number PZ(� 3 87 State L� Color �-'��e Zc�o2 /�e►�e 1�1 Crv,Z
Registered Owner ��-,¢w,,,, �,��/ ,i}„i,,,,i,<< �031� BC����e��
Driver of Vehicle n�--rr� E/,z,;L��r.e, ,�,,��,,,.,
Area Damaged
City Vehicle: Year Make Model �/e�,�ff#3 (�/��
License Plate Number State Color �y q y/�(a����Z
Driver of Vehicle(City Employee's Name) 67� pTU ('�t�U�
Area Damaged C��er.�
,�l f�� Sl�e,�.
Iniurv Claims-please comnlete this section �d check box if this section does not applv �r��
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 a�d 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 1��/��
Print the Name of the Person who Completed this Form: �I� � ' ���c��i�--
Signature of Person Making the Claim:
Revised February 2011
DEPARTMENT OF PUBLIC WORKS
Rich Lallier,Director
CITY OF SAINT PAUL Kevin Nelson,P.E.Street Maintenance Engineer
873 North Dale Street Telephone: 651-266-9700
__ Christopher B. Coleman,Mayor Saint Paul,MN 55103 Facsimile: 651-266-9736
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Cky M AmsMu
December 14, 2012
Philip Steger
1162 Thomas Avenue
Saint Paul,Minnesota 55104
Re: Vehicle License#671DJLJ
Dear Mr. Steger:
This letter is to express our sincere apology for the inconvenience caused during the recent snow emergency
where you were towed and/or 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,
,
� i�"� :
Kevin Nelson .
Street Maintenance Manager
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An A,ffirmative Action Equal Opportunity Emplayer =. k�Nr.p�_._°>`
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Saint Paul Police Impound �ot, 830 Barge Channel Road, Vehicle Release Form
Make: 99 HONDA License#: 671 DJU CN: 12288997 Invoice#: 17940
r e: 123.95 ��
DatelTime Released: 12/28/2012 13:23 Tow Cha g $ /_�
(� �`
Released to: TOTO Storage Charge: $ 270.00 � '
Paid by: CREDIT CARD Admin Charge: $ 80.00 ��
�
Released by: SHANNON Tax: (7.625%) $ 15.55 � � 9
� � /�
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 489.50
I will check the vehicle for damage or any other problems that
may have occu�red 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: $ 489.50
on this form prior to leaving the impound lot.
Damage and/or other problem: N�r��,�„`��,.
$eca.ksc �� !�w s��rol
�hr,(� ��c�••i�i.a F'�c
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Police Report made: Yes_No_IF Yes, CN , If NO,Why? wt ,�;�Y� w+,.l�s� �•
�el�,�a�e �-w vet-+tGe
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT """h' 'L�zE>f�L�
Signature s�2000
___� __ _.-- - _ _ _ _ � .
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� Citation# 8 8 8 ��a 26
i • , ST. PAUL
"+ She uEde sMned,Ebei�nT duR swo EY DI�STRs/her�oa h de oses and sa s: I IIIIII IIIII IIIII IIIII(IIII IIIII IIIII IIIII IIIII�III IIII
9 9 Y P P Y
; * 8 8 8 7 4 9 2 6 7 *
, Date of Offense `�'� � ,J /��° Time of Offense �'�� �'
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Veh.License No. !_"%� � ��t'�- Yeae' �� State ��ry'�'� Make ' '•f= ` ` Style ` '� Color �` :��
1 � .. �'} �,. .t �...�-f, • . l'� 14±. ;t . �I � A%."`
Location of Offense: u� �<#� �1+�'��'��,; : (> 1�! ` s �' � f !
VIOLATION: � SNOW EMERGENCY St. Paul Ordinance 161.03 FINE $53.0�
(Amount includes mandatory state surcharges of$13.00)
i CN i��U��� ,
' Citing 1-. �C� � Officer �}�� ` Citing
i
Officer -`� Number Dept. �` -�'�
, �Posted Night Plow ❑Day Plow ❑Plowed in(Windrow) agged Before Plow �Drove Off
, �;
OFFICER'S NOTES
❑NO PLATE VIN:
Citation can be paid at the Impound Lot.Please r�ad the back of the citation for payment,instructions.:�;:
�
CITATION
_ - - — -- —---� �
- - - ---—------ -- _ _
Citation# 8 8 8 ������
ST. PAUL
' STATE OF MINNESOTA-RAMSEY DiSTRiCT COURT (IIIII�IIII IIII)IIIII II�)I IIIII I��II IIIII IIIII II�IIII
e undersi ned bein dul swom u on his/her oath de oses and sa s: I
Th 9 � 9 Y , P P Y —
* 8 8 8 7 4 9 2 6 4 *
Date of Offense � .' �' ''-� � ' � Time of Offense �'`�' n ' �
�
�
�� � Plate ,"?..
Veh.License No. � ~� �J' � Year ! � State ry �`' Make ' i � Style � Color �
t�. ��.
Location of Offense: '" � �s � `"'' "��-�
�� VIOLATION: -�'� SNOW EMERGENCY St. Paul Ordinance 161.os FINE $53.QQ
(Amount includes mandatory state surcharges of$13.00)
�dj CN ��-�°" ���
3 � ��� � F � � .
# Citing {�� �,l r� Officer � �. ! Citing �t;,��
Officer � � '`���'�� Number Dept
C�osted Night Piow ❑Day Plow ❑Plowed in(Windrow) ��C1Tagged Before Plow ❑Drove Qff
OFFICER'S NOTES
'� ❑NOPLATE VIN:
Citation can be paid at the Impound Lot.Please read the back of the citationfor payment Instructions.�?' '
CITATION
_ � ., _ ...
� �_ 8�� i ��lL�i�
,
� Citation#
ST. PAUL IIIIII
� - ` I IIIIIIIIIIIIIIIII
s IIIIIIIIIIIIIIIII
T I IIIIII IIIIIIII *
� STATE OF MINNESOTA-RAMSEY DISTRICT COUR * 8 8 8 7 4 9 2 6 2
The undersigned,being duly swom,upon his/her oath deposes and says:
- -y . ',��t
Date of Offense ��-- �''�'� / j �` Time of Offense`�` � ' : .
: _ `� ,r ';;
� Plate Color u�'{�—
"' a ��� Style ,. .
s ��.�. ��� Year � � State �" ' � Make
Y
Veh.License No. �
{. A � � _ ...� n•.
. . � i� tf; .. '9}'•-��"�`� .1��,t ��� ..
i f ', '� l_�4• c ``.a11 i � . �
' Location of Offense; �
� . FINE $53.00
VIOLATION: '"� SNOW EMERGENCY St. Paul Ordinance 161.03 �Amount includes mandatory state surcharges of$13.00) ,
`-i ��,f�j�y� '�'' r,
�N ' � -�}� ; Citing � �, j
� Officer E Dept.
Citing �', (:�.��� Number � .
Officer � ` • ❑Drove Off
❑Day Plow ❑Plowed in(Windrow)
�Tagged Before Plow
�pPosted Night Plow
OFFICER'S NOTES
❑NO PLATE VIN:
Citatlon can be paid at the Impound Lot.Please read the back of the citation for payment lnstructions.
CITATION