Story �. �
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.OS 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 eaplain 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 �r,�/Q/ Middle Initial G Last Name s�o R y T�
Company ar Business Nam:, � 1� C ���o �ERVrC'FS
Are You an Insurance Company? Yes� If Yes, Claim Number?
Street Address �lo �D �Gc/�?B�iQ�AN� ST ��
City �7 T"�Gt L State /�Jy Zip Code //'
Daytime Phone�� - Cell Phone (�)�- L3��Evening Telephone (� -
Date of Accident/Injury or Date Discovered ,2 �//-/.3 Time ,'u�D a pm
Please �tate,in detail,what occurred(happened),and vvhy you are submitting a claim. F:ease indicate why cn c��v you
feel the City of�Saint Paul o/�r its employees are involved and/or responsible for your damages..�fio,�Q � Ca�v'on �'�t.
��rG(�/ /'h �'+rovti`�' d7' OGl✓' v+�olr7�"J+►� Gi.� `�O y0 �Gth�+��v�Avt(�l�'✓ ./�TC✓ ��l, cs�-OVtJ SI�~M
t.�e, we�^G �-� �c� -�o �.e�e �,l.� coi,�s v-�' �'Lr- �S'�r�.c.7` �So -,�'��,� e6r.�J�,oJo�,.��`'.(e. ,�4.r�`-yre.rr�
.4e�1'.3'. G�c, Q,r� 1+�..,... •-u�- �-N : R ' .' o s� �-/o - i�,,
� `�,c.k ��.c .s �/Y-eo,o[ GJe l�l�e - �-i3
�n��9�'�i Cs�✓.� Li a,�b a,eH �i`'ckef�(. 1�-� o,,�o�w aQ .?'3 o a...> A-.'�T�R �t. .o%wl"-f
e2h. G�or.,G l�v�o� wG. /lfe �.�'�'i(.y Low! �w.s'q�e.�c.. v ea�v ort cSy''ti°�'7�C
�,.•,-�� �o oln> wa/Ct.� t L's v w- rK.�hevd, p�./y /�y t a 6 e.cn ,�t cllcf- Y' �dw e�Q r�
Please c'heck the box(es)that most closely represent the reason for completing this form: �r 1l-''o�,a/-�Al�e.
❑ 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 y^�� nPpd to include copies 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
�1'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 damaged items
O Injury claims: medical bills,receipts
j�l(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–please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unlrno (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.
S`D /� `rro C a�,�e�la K oC �S'-f.
Please indicate the amo t you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ir•.e. �J.��k. 7"� ,�i.., „� f,�,c n�' 39, O� ,,, ,s �
6�t�4 �r�ets �S w�� /I /�/ � �7 /� �'�J
! Y i-�d'u.t-LC GtT"G L2�p /x-r .��ti.t, A-�►-r3c G✓G �tae(�
/Y+— 0 2 e.a,�r ba�k� Br►� .��'r'�-�7c',-- - ✓
Vehicle Claims– lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year {9 9 R Make , j a ,,� Model C,o�br:o �r, n eN;�A 5/t
License Plate Number U,�� State�J�/ Color Y C C h
Registered Owner Q,�,- ��. �,.
Driver of Vehicle_ ary � �j�,,r y �j�r
Area Damaged '
City Vehicle: Year Make Model
License Plate Num State Color
Driver of Vehicle(City ee's Name)
Area Damaged
Injurv Claims–nlease comnlete this section � [H'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 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)1
� Name of your Employer:
Address Telephone
Check here if you are attaching more pages to this claim form. Number of additional pages �2 .
/3 1 ofia; �°`,��
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 � ' p�� —/3
Print the Name of the Person who Completed t is Form: � r � v�'ov- Y-,
Signature of Person Making the Claim:
Revised February 2011
. �
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 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 G��y Middle Initial C7' Last Name c����y J �
Corr�pany ar�usiz�ess Name G f e �u,o cSE�I/.Z C�-S
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address �� �� �L�/Yl�rER L/g/Y17 �7' ��
City c5% /��GtL State /�i'1� Zip Code S�/ �
Daytime Phone (� - Cell Phone G( �.Z)Y0� �O3�y Evening Telephone(_� -
Date of Accident/Injury ar Date Discovered �—��'/.3 Time 7:3 D am pm
Please state,in detail, what occurred(happened),and��hy 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. T li a� � C�Ar,,s
�n �'�i 2 S�r�t�� 1 r 'T•�"`�f �'t O u-� O�PG�"'7�"/f►t�w� (L� ��7� �fi4w.��r/Av�o.� �• !7`T-7-e y' �
��12 s/totn/ $'v"�e�rr.�. GjE. WC�"�- ��� 1"p �YI CI!'G /HC Co.'r.S Sd�-f "�/�G ��'t f.f" .S v J^Gy
k.l r�C. ,o%w '.��� Fa.9�— G��'� �' d'. �� yno v'�CQ ;�CN- o-�-� 7��t �S�v�tG'f" t�r+,¢!�1
' nt � �' .2—!0 —/3 �� ly+-c e, T,!� �.c.t�f-�' o�.c� /r���,
� /o , s /- �L —��../3 o►.�d2 �.t•� f,`clle� ��
Av'Ov� % 8 Gt Tt% �/�. �t�l�✓r �t���O'�►tt, '��.ti 0��. .GTO��� �O w.���ia V`�fp�Y
W a s o.w. Oti�or Ca,-s o x �-s/'rc�t wTs��,. �o%w w.. f c�e ver J.n 5�+-o�,a. d•,� �•.y-f-w o �
Please check the box(es)that most closely represent the reason for completing this form: h�o� �`K�o�� �` �aG,
❑ My vehicle was damaged in an accident ❑ My vehicle was damage d�uring a tow �f� , �
❑ 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��ou need to include copies 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 V�ILL 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 andlor receipts for the repairs
�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 damaged items
O Injury claims: medical bills,receipts
J8�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—please complete this section
Were there witnesses to the incident? Yes No Unlmown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unlrnown (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 det iled as possible. If necessary, attach a diagram.
�F C7 /� �� � l�y»6er!o„n� �'f:
Please indicate the amou you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � ., �,.�� �jQ��[ �'�. �j.-,ppu,r,� �e.eJ' p-�' ��39 D D arc,Q o��..r�i�
� ot� �f-�cl:¢ts, a►:s �'�lc.v �-✓e��t :�'swec� a.-�tew �/�.,�.KQ elo� a,w�.�P �.✓e �a..�
yn�v�t-o c a�s bae�c o•1.f o ��-,r�e f..
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year��Q Make n � Model A,•� a� j/
License Plate Number �S'��Q 3 0 9 State,�jpL Color (�.ro�,�,
Registered Owner Gtr �f r „-
Driver of Vehicle o,M o� �r
Area Damaged
City Vehicle: Year�� Make Model
License Plate I�Fu�nber State Color
Driver of Vehicle ' Employee's Name)
Area Damaged
Injurv Claims—nlease comnlete this section � Ly 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 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 wark?____ __ ___ _(provide date(sl)
Name of your Employer:
Address Telephone
LtiJCheck here if you are attaching more pages to this claim form. Number of additional pages ��.
J? o+a,l ��t'9e S'
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 � -02 D -/3
Print the Name of the Person who Completed his Form• r' � �7�0�` r
Signature of Person Making the Claim: ,�,
�"
Revised February 2011
i
t �'''� I �
Attention: Amy Brendmoen, Councilmember (Re: Telephone conversation
regarding unjustified ticketing and towing of my 2 cars on 2/11/13)
Gary Story <gandcautoservices@gmail.com> Wed, Feb 20, 2013 at 11:24 PM
To: ward5@ci.stpaul.mn.us
Dear Ms. Brendmoen
As per our con�ersation, I am sending to you duplicates of everything I am sending to the City of St Paul
regarding these claims. I ha�e lived in St Paul now for 3 years, and have been pretty good at keeping up with fihe
snow plowing times and moving cars around. We just mo�ed to this side of town this last fall and I thought I had
it covered.
After the snowfall the weekend of 2/10/13, I moued the Volkswagon and Pontiac, offi of the street in front of our
apartment building, so that the plows could plow the East-West side. I mo�ed them back onto the street on
2/10/13 at 9:00 pm as the plows had finished much earlier in the day as evidenced by photos 4A which shows
the Cadillac sitting in front of the utility boxes on 2/10/13 with the plow wake around it and 3/4B which shows
the same area after I mo�ed the Cadillac down further. You can plainly see that the plow had already come down
the street. Photos 1 & 2 are continuing down the hill and you can see where my cars were parked when ticketed
and towed at about 2:30 am on 2/11/13, while we were sleeping. You can also see that there was no further �
plowing done, as it had been done the day before. There were other cars both up and down the street that were
in plow wakes and also covered in snow, that were not tagged nor towed.
According to the tickets issued, they claim that they were tagged before the tow and that the Volkswagon was
plowed in. That can not be, as the plow came down on the day of 2/10/13, had already been plowed before we
mo�ed the cars back to the street the night of 2/10/13 at 9 pm, and as you can see from the diagram on photo 1,
there is no plow wake...and there had been no further plowing on our street since the day before.
I took these photos when I retumed from the Impound Lot with my 2 cars which they charc,�ed me $439.00 to get
out. They also gave me the 2 plow tickets that had been written at 2:30 am on 2/11/13, the day after the plowing
and I had moved my �ehicles back (at 9 pm ) before going to bed.These tickets are for$53.00 each, which is
another$106.00 that I feel I am being unjustly charged.
As I said before, there WERE other cars on the same street, both uphill and down, that WERE in plow wakes
and co�ered in snow. They were still there when I got back. I don't understand why I was singled out and my 2
�ehicles were unjustly ticketed and towed.
I would appre�iate it if you could look into this matter for me. I would like the City of St Paul to retum the
$$439.00 already collected from me for the Towing and Impound Costs, and I would like both of these Plow
Tickets dismissed.
Thank you uery much for your help.
Sincerely,
Gary G Story, Jr
1640 Cumberiand St #1
St Paul, MN 55117
4 attachments
�� Claim Forms.odt
4971K
�� Explanation And Photos.odt
10882K
,� Impound Fees.odt
980K
J� Tow Tickets Issued Day After Plow And Cars Moved Back.odt
1020K
�
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i 830 BARGE CNANNE�RD
SRINT PMA. rki. FS107-2450
I651-266-5642
tlarchent lU: d�63t3N144
Term ID: 0017340000800638014906
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�� Saint Paul Police Impound �ot, 830 Barge Channel Road, Vehicle Rei�ase Form
. Make:97 VOLKS License#: 384HVL CN: ?3027844 Invoice#: 19427
DatefTime Released: 02/12/2013 11:27 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.Q0
Released by: RYAN Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotai: $ 219.50
i wili check the vehicle for damage or any other problems that
may have occurred wh+ie 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.�
on this form prior to leaving the impound fot.
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
Signature 5�2000
1
�
� Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 00 PONTIAC License#: SER309 CN: 13027844 Invoice#: 19428
Date/Time Released: 02/12/201311:32 Tow Charge: $ 123.95
��Released to:TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00 �
1
Released by: RYAN 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 vehicie 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 leavmg 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
Signature �2000 �
�
� � �� �g a���:
��� Citation# ,�� ° � ,.�
ST. PAUL 9�
. IIIIII�������II
��»�IIIiI III�I
III�II�III�I_
I�illllllll _ *
�ATE OF MINNESOTA-RAMSEY DIS�Th►�?e�oauh deposes and says: * g g g 7 � 3 0 7 2
�e undersigned,being duly sworn,upo • ��
D � ��� � �� Time of Offense � ,.f� G�'` �+/� ����
ate of Offense ��KSw "� Color__----
� � Make � ------
u v�Ptate 1� S�Y1e
� 1 Year State_____---- ���a �
�eh.License No. � /� ,t �
�� �
_ocation ot ottense: FINE $53.0�
VIOLATION: � SNOW EMERGENCY St.Paul Ordinance 161.03 �Amount includes mandatory state surc rges of$13.00)
� �
CN ���� � � Citing r �
Officer S Dept.
Citing Number
Officer �agged Before Plow ❑Drove Off
�sted Night Piow
❑Oay Plow owed in(Windrow) �—
OFFICER'S NOTES
❑NO PLATE ��N� ment instructions.
Cltation can be pa�d at the Impound Lot.Please read the back of the citation for pay
CITATION _ _ _ ___. _ ._ - —
�
i
Citation# ~��� ��� ��
ST. PAUL III
• ` I'III
. IIIII
. I IIIII
III�I
IIIII
III�
I��
� *
I
I'�I�III
tTATE OF MINNESOTA-RAMSEY DISTRICT COUR7 Sgs and says: * g 8 S 7 5 2 5 9 8
"he undersigned,bemg duly sworn,upon hislher oath depo
�`' � � / Time of Offense �}^ � � � . , t / - .(''{�d �
)ate of Offense/" �% � S��e V�� Color�
5 � , Plate � � �Make
Year_._.L-State
Veh.License No. �
%� 0 / C�-
�ocation ot offense: FINE �53.0�
ViOLATiON: � SNOW EMERGENCY St. Paul Ordinance 161.03 (A�nt includes mandatory state surcharges of$13.00}
/� 3 v � 78 y� Citing ��
CN � Officer � �� Dept.
Citing Number
Officer ❑Drove Off_
indrow) b�a99�Before Plow
❑�ed Night Plow
❑Day Piow �Plowed in(W.
OFFICER'S NOTES
❑NO PLATE VIN:
Citation can be Paid at the impound Lot.Please read the back of the citation for payment instructions- _�
CITi-,i iOtJ _ _ _._ _ __..
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