Torres ���1�",t��U
JAN 2 3 2013
NOTICE OF CLAIM FORM to the City of��►�`�F��, Minnesota
Minnesnta State Statute 466.05 states that "...every person...wiu�claims dam�eges fr�m any municipaliry...shall cause to be presentea to the
governing 6ody of the municipaliry within 180 days after the alteged loss or injury is di.ccovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation nr other relief dentanded.°
Please complete this form in its entirety by ctearly 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 rnmpleted. 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 f�e�� Middle Initial � Last Name �� �rt S
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address ��� I,IIQS�i f2 GI��Q,
City 'V l0 J 11t� S V 121� State M./V Zip Code 5 S��l�}"`
Daytime Phone(_) - Cell Phone (�),�- °/� Evening Telephone( j -
Date of Accident/Injury or Date Discovered �e�-" �q'��(� Time�_am/pm
Please state,in detail, what occuned(happened),and why you are submitting a claim. Please indicate why or how you I'
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
i
Q- P�Aaf M8R o Pu6�iC WOrKS h�Eo�Qc� o M KP SROW Q,M rq��.*1Gy OIoW Qn�.
� W�aS ►no�l- aMrO�rB o�E klnt,�e f�±an�e.
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 you need to include couies 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
O Towing claims:legible copies of any ticket issued and a copy of tt�e impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease complete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circlej
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possibl If necessary,attach a diagram
h�! U�l. Ni.�nnt�a�na lAve b2�wB 1�' O�,�or�l S� an� N �o►�45wor h S
Please indicate the amou t you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � �-� af, 5 0
Vehicle Claims- lease com lete this section ❑check box if tlus secrion dces not a 1
Your Vehicle: Year�_Make Model Td► DQ
License Plate Numb�r�.�v�-$� State�!(_�olor 6�VC
Registered Owner �Ken� 8arral� `1�onre�
Driver of Vehicle YCS
Area Damaged y�Or�e
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged i
In_iurv Claims—please complete this section �check box if this section dces not a,� l�v
How were you injured?
What part(s)of your body were injured?
i
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 ; Telephon�
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 pag�s to t'claim form. Number of addiNonal 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 �` a �' �3
Print the Name of the Person who Completed ' Form: �e� �a rra ZA �b rr'2S
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: 65]-266-9700
Saint Paul,MN 55103 Facsimile: 651-266-9736
�
The'�os:Lirac:e �
Giq in Am.cri¢
December 14, 2012
Rene Barraza-Tones
_____ __ _ _ _
Jose Barraza-Torres
2241 Chesire Circle
Mounds View, Minnesota 55112
Re: Vehicle License#2BV288 '
This letter is to express our sincere apology for the incdnvenience 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 riot aware of these changes when we declared the
De�ember 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 apoiogy for the ineonvenience this has caused during this snow emergency.
Sincerely,
" ' �`I
V .
,'�"^.�+/ + � �/!�'ti�
/
Kevin Nelson
Street Maintenance Manager
Q,�=;.�se,,,
�� + '`
W��-: �+�y .
t q 9
` : An A rmative Action 1 O ortuni Em 1 er -
ffi Fqua pp tY P�3' % SA�NT PAVL i
< NbllC WOW(5 y
°,%,. �i
4`�P
�aint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 01 CHEVROLET License#: 26V288 CN: 12288997 Invoice#: 17826
Date/Time Released: 12/10/2012 16:17 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CASH Admin Charge: $ 80.00
Re!eased by: YOUA Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
I wili 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: $ 219.50
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 PROTECy,YOUR RIGHTS, REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
_
; ;j� z--=`--_
Signature ��-�✓, v sti��� 5i2000