Korey NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.03 states that"...every person...who claims damages from any muxiicipaliry...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 amouni 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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. This form must be signed,and both pages com�leted. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,290 CITY HALL,SAINT PAUL,MN 55102 ,
First Name ��Qd Middle Initial � Last Name REC'E�VE� I
Company or Business Name, if applicable
FEB 4 20i3 ��
Street Address ���`^1 �Z'��,rn�'� �,X1 �(��}- � ����� ,
City�� Qc�,1, State.� Zip Code
Daytime Telephone (�2 ) , r-(�J� Evening Telephone��) �Q �^7��
Date of Accidend Injury or Date Discovered �"'L..�~I�I 12. Time � 'l am/�(m circle)
Please state, in detail, what occurred, 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. �
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Please check the box(es) that most closely represent the reason for completing this form:
❑ Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
�.�'ehicle was wrongfully towed and/o��ticketed ❑ Injure�on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
❑ Other type not 1'rsted—please specify
In order to process your claim you need to include conies of all anplicable documents. This is a general
guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
�Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates,detailed.list of damaged items
O Injury claims: medical bills,receipts
O Photographs can be provided but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
�
Notice of Claim Form, City of Saint Paul,page two
All Claims—nlease comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
If yes,please provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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 helpful, attach a diagram.
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Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do ioxecnlve rhic .lair�i�y.our satisfaction. �,�.,A�_- i .s�- �,�S l.l��y,,
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Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 1 Make G��� ' Model fYlo��i�w
License Plate Number �f�/1�,,�_ State� Color �,1�,� '
Registered Owner �
Driver of Vehicle ��
Area Damaged___N�,� �
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's ame)
Area Damaged
Iniurv Claims—please complete this section �check box if this section does not applv
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 treat�ent? (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 infonnation you have provided is true and correct to the best of your knowledge. Unsigned
forms may not be processed. Submitting a false claim can result in prosecution.
Print the Name of the Person who Completed this Form: ��� �'�c�►
Signature of Person Making the Claim: ���,��-
Date form was completed � 1�51�� Revised Apri12006
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Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 98 CHEVROLET License#:TMP110 CN: 12288997 Invoice#: 18092
Date/Time Released: 12/15/2012 17:27 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 75.00
Paid by: CASH Admin Charge: $ 80.00
Released by: PHENG Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 294.50
I will 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 lmpound Lot staff Total Charges: $ 294.50
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 PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
, /J � . 5/2000
Signature� �
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DEPARTMENT OF PUBLIC WORKS
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_.Rish I:all�e�--�irector
CITY OF SAINT PAUL '' Kevin Nelson,P.E.Street Mai tenance Engineer
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Christopher B. Coleman,Mayor �` 873 North Dale Street Telephone: 651-266-9700
SaintPaul,MN 55103 � Facsimile: 651-266-9736
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The Mos�Livable
Ciq In Ameri�
December 14, 2012
Me�an Thoie°-- ____--
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Ahmed Korey �
1597 Jessamine Lane, #F
Saint Paul, Minnesota 55106
Re: Vehicle License#TMP 110
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 ticke-�t�v�i�l.be forgiven
and any towing and impound lot fees will be refunded to you. Please contact us at 651-266-9800 to arxange for
reimbursement. `
For all future snow emergencies, you should note tl�at 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,
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Kevin Nelson �'
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Street Maintenance Manager
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