Arnold �ECE�
JAN �3 ?0�3
NOTICE OF CLAIM FORM�j��Saint Paul, Minnesota
Mirtnesota Statr Statute 466.05 states tha�"...�very prrson...who clairns damages from any miaucipalitv...shall caus�Jo be presertted to the
goveming body of dk mweicipaliry within 180 days after rhe alkged Ioss or injury is discovered a rwtice srating rl�e rime,place,and
circumstances tlu�cof,and the amowt of compensarion or othcr relief dcmanded'
Pkase complete this form in its entiretY b3'�Y h'P�S or printlng your snswer to eac6 question. If more space is
needed,attach additionai shcets. Pka9e note that you wHl�ot be oontacted by tdepbo�to darify answer�,so provide as
mach information as�sary to ezplain yonr daim,and t6e a�ant ot oo�easatlon being req�ested. You vrift receive a
wrItten acknowtedgemcnt once your form is reaived. T6e prooess can whe up to ten weeks or loager�p�dina on the
natnn of your claim. This[orm must be�,and both pages compkted, If something dces 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
n /�
First Name�0��h Middle Initial,�Last Name 1-� tr*n o � �
Company or Business Name
Are You an Insurance Company? Yes/ o' ff Yes,Claim Number?
Street Addcess i�� � �t 1 t r n�h�h ��!e �,�
City � i r� � �czc� � State ��\� Zip Code T ,�i
Daytime Phone(� - Cell Phone(��2)g��Evening Telephone(� -
Date of Accident/Injury or Date Discovered 2 �2- _Time am/pm
Please state,in detaii,what occurred(happencd),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.
. .
� •.
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
❑�riy vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a ptow
[�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 copies of all auolicable documenks.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WIl.I,NOT be returned and become the propeRy 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 vetricle if the damage exceeds
5500.00;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 tiamaged items
O Tnjury claims: medical bills,receipts
O Photographs aze always welcome to document and support your claim but will not be retumed.
Page 1 of 2—Please complete and retorn both pages of Claim Form
Failure to complete and retnrn both pages will res�tt in delay in the handling of your claim.
All Claims-alease comnlete this section
Were there wimesses to the incident? Yes � Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforce�ent 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 pazk or facility,
closest landmark,etc. P�ase be as detail�d as possible.. ff ne��s�ary,attach diag�am.
�-Z r^, a a s J�- a � lV i"i'n r< <- ��g �' c� v e
Please indicate the amRunt you aze seeking in c m nsation o wh you would like the Cit to do to resolve this claim
to your satisfaction. . �r. "� � #-+ � �c� � �'
� W T -b .�-- i - ~L.��
Vehicle Claims-olease eomplete this sectton / C3check box if dris section does not aonlv
Your Vehicic: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vetucle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
�jury Cla[ms-please comnlete tl�is sectlon �heck box if this section does not app1Y
How were yau 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 da[e(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
C3 Chedc here if you are attaching more pages to this claim form. Number of additionsl pages 2- .
By signi�g thu form,you are stating that aU informatior�you have providid is true aRd correct to the best
of your knowledge. Unsigned forms will not b�e proeessed
Submitting a false claim can�ssult in prosecution. Date form was completed i /T�� :/L� ( �
Print the Name of the Person who Completed this Form: J o '�' 'r`�' �
i s
Signature of Person Making the Claim•
Revised February 2011
DEPARTMENT OF PUBI.IC WORKS
Rich I,allier, Director
CITY OF SAINT PALJL Kevin Nelson.P.E.Street Maintenance Engineer
Civistopher B.Colemax,Maryor 873 North Da1e Street Telephone: 651-266-9700
Saint Paul,MN 55103 F'acsimile: 65l-266-9736
ra.n�:.�.er
c�,.,.��
I)ecember 14, 2012
Natalie Olvera
1247 Wellesley Avenue
Saint Paul,Minnesota 55105
Re: Vehicle License#083BJC
Dear Ms. Olvera:
T'his 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 plaw route changes in your area d�te to the
light rail construction. Due to a gap in notification,you were not aware of these changes when we deciared 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 651-266-9$00 to arrange for
reimbursement.
For all future snow emergencies,you should note that the day plow/night plow rules will be followed and no
additiona!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,
�� '��'n�ti
L�
Kevin Nelson
Street Maintenance Manager
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Date!T:me� ?2/1(3/2.012 G8:53 l�voice �: 1?929
V��:icle P!ate: 0836JCJ��tN
Pay�r: OWNE� Loc�tior� Pa�d: Im�o��nc! Snow Lat
Ci«►t�on� Am�uri�t:
8t�874�28� $ 53.00
'�'�ta! .�mount �a?�: $ �3.OG
Paid by: C4�H
iCEE� �!H�� �C�FY F�� Y�l>R F�ECG�DS
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 96 SAAB License#:0838JC CN: 12288997 Invoice#: 17929
DatelTime Released: 12/10/2G12 08:53 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CASH Admin Charge: $ 80.00
Released by: ELISE Tax: (7.625%) � '5.55
I,the undersigned,have recovered the vehir,le d�scribed above. Subtotal: $ 219.50 /� ,
I will check the vehic!e for damage or any othe�problems that f �
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 / �
Saint Paul Police Department. f acknowledge I will report (
damage andlor any other problems to the Impound Lot staff Total Charges: $ 219.50 � -- ---��.
on this form prio�to leaving the impound lol.
Damage and/or other prablem: —
Police Report made:Yes_No_IF Yes,CN , If fVO,Why?_
TO PROTECT yQ�JR RIGHTS. F�POf�T ANY PFtOBLEIV�DAMAGE BEFORE LEAVING THE LOT
Signature ���