Crocker (2) r
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 6ody 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 elcplain your claim,and the amount of compensation being requested. You will receive a
written aclaiowledgement 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 S o� ri Middle Initial s Last Name e �� ����'r' ��
Company or Business Name
2�12
Are You an Insurance Company? Yes/�o If Yes,Claim Number?
11� 8 )�►a�c�,s ,4 ve, ����`��
Street Address �-
City S-�.�Pa�n 1 State � �� Zip Code .SS/v`
Daytime Phone(�S� ) �1���Cell Phone 6( ��� )9�3-��Evening Telephone(6S! )983-7y9 q
Date of Accidend Injury or Date Discovered�/0 �� � � � 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 City of Sfaint Paul or its employees are involved and/or responsible for your damages.
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�`c.�L-e �" u u� �`0��
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
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include couies of all anplicable 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
� 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 dasnaged 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—ulease complete this section
Were there witnesses to the incident? Yes No Unlrno (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No �?i 'o (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, et�ca. Please be as de1tailed as ossible. If necessary,attach a diagram. r +
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Please indicate the amount you are seeking in compensption or what you would like the City to d to resolve this claim
to your satisfaction. �a7 2 .S � , ?e��►��l w.., c✓zul�'� ���v� �r 1�� w�t C. ��•��lL,
Vehicle Claims—ulease complete this section ❑check box if this section does not avplv
Your Vehicle: Yeaz O� Make�o r� Model u w e�r-
License Plate Number 16 6 N S p State l��Color � e
Registered Owner�')o1�v. Cro�lc.tr
Driver of Vehicle�To�h. Cro�Ke✓-
Area Damaged r.n��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In_iurv Claims—nlease comulete this section [�check box if this section does not avnlv
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 will not be processed. .
Submitting a false claim can result in prosecution. Date form was completed �2�, S�/�
Print the Name of the Person who Completed tlus Form: � o�� Cr o GK e r
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
Christopher B. Coleman,Mayor 873 North Dale Street Telephone: 651-266-9700
SaintPaul,MN 55103 Facsimile: 651-266-9736
��
The Mosc LMWs �
City 1n Amerk ,
December 14, 2012
John Crocker
1108 Thomas Avenue
Saint Paul, Minnesota 55104
Re: Vehicle License#166HBP
Dear Mr. Crocker:
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.
Forthis snow even�,c�ue to the laci�of communication regardingthese route changes,the ticket wiii be forgiven
and any to`uing and impound lot fees wili be refunded to you.Please contact us at 651-266-9800 to arrange for
reimbursement.
For a11 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 �
i�(A"L+�✓� �1�
Kevin Nelson . .,
Street Maintenance Manager
�S� .',O . ���sive9�Mc4
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• � s . An A,�rmatrve Action Equal Opportunity Employer � SAINT fAUL 4
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Saint Paul Police impound Lct, 83Q Barge Cf�an�el Road, Vehicle Release Form
Make: 02 FORD License#: 166HBP CN: 12288997 Invoice#: 17979
� �
DatelTime Re�easeo: 1 2/10/201 2 08:36 Tow Charge: $ 123.95
Released to: TOTO Siorage Charge: $ 0.00
Paid by:CREDIT CARD Admin Charge: $ 80.00
Released by: `LISE Tax: (7.625%) $ 15.55
I,the u�dersigned,have recovered the vehicle described above. Subtotal: $ 219.50 --.�
I will check the vehicle for damage or any other oroblems that �
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 z`-' !
Saint Pau{ Police Department. I acknowledge I will 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 otner problem:
Police Report made: Yes_No_IF Yes, CN , If UO,Why?
TO PROTECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
� Signature � 5i2000
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