Kulka 1���E1�'ED
FEB 2 8 2013
NOTICE OF CLAIM FORM to the City of Saint I�'�i�i�sota
Minnesota State Stalute 466.05 states that"...every person...who claims damages from any municipality...shall cuuse to be presented to the
governing body of the municipality within 180 days a,fter the alleged loss or irtjury 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 quesbion. If more space is
needed,attach addifional sheets. Please note that you will not be contacted by telephone to darity ancwers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acl�owledgement 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�ed,and both psges completed. If somet6ing 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
'/� �
First Name ��� Middle Initial�Last Name f1 f J � K�
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
' � �� �} � � i� `' �2�,���
Street Address t �
City (`� �. U!"',���Jl���l`�1� State �� �; Zip Code `�`����.
Daytime Phone '(;}���'1 - \ ��J Cell Phone��--�7�7Evening Telephone( �F�.�- "i - �-7�
Date of Accidend Injury or Date Discovered �'� � � 3� I�j Ti� ��am/�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or i�tLs employees are involved and/or responsible for your damages.
�E;P� �TI Gt C�1�E%C� �1>1� ��C:v�i-I �'�--�G� � � �
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 conies of all anulicable dceuments.
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 damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be retumed.
Page 1 of 2—Please complete and return both pages of Claim Form
i
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 wimesses to the incident? Yes No Unkno (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? � No�p Unknown (circle)
If es,what department or agency?�� • cLti" ��/r� �rt �' `Case#or report# � �i-� �('�I 3 I�
Y
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. rP'lease be as detailed as possible. ff netcessary attach a diagram.
-� `�f''c-�� cX A<< \ C�R v'1� l,\�Q`=> >����1 �<:� ��', ��. � U�l�-� �'•.'h�l'�c-1,�i Y'l �• a,«�
Please indicate the amount you aze seelQng in compensation or what you woul�i like the City�o do to resolve this�claim
to our satisfaction. .-�- �.rn C��:�r rt in-� �-,� �I ct�t��rt�' �k -�v v�;;�' ��n�F -�-�e'
�G'� G` Y1/l c � 1� .
Vehicle Claims ulease rnmUlete this section ❑check box if this section dces not avvlv
Your Vehicle: Yeaz Make Model
License Plate Number Srate Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims nlease comnlete this section ❑check box if ttus section dces not avnlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treaxment? 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 yow injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�l Check here if you are attactung more pages to this claim form. Number of additional pages�.
� �
By signing this form,you are stating that all inforniation you have provided is true und 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 =� I �� 3'���
Print the Name of the Person who Completed this Fo -� v ��' � � �
Signature of Person Maldng the Claim:
Revised Febmary 2011
I
Monday, February 26, 2013
Rebecca Kulka
11354 Xavier Road
Bloomington, MN 55437
On Thursday, February 7, 2013 at 11:30pm,the Bloomington Police came to my home on behalf of the
St. Paul Police Department an Officer Maloney asked them to inspect my vehicle because they said I
hit someone with my car. I told them I did not hit anyone with my car and the Bloomington Police
inspected my vehicle and found no damage or indication that my caz had hit anyone. They informed
Officer Maloney that the vehicle had no damage;however,he told the Bloomington Police that he
wanted the car towed and put on a hold and the St. Paul Police would have the caz towed from
Bloomington to St.Pau1 for fiuther inspection.
My attorney made several attempts to contact Officer Maloney but he never responded to any
messages. After several days,my attorney learned that because Officer Maloney is a street cop and not
a Sergeant or Investigator he did not have the authority to request a hold be put on my vehicle. After a
week,my vehicle was released by the St. Paul Police Department. My vehicle was never towed to the
St. Paul Police Department and was held for one week by them. Because Officer Maloney did not have
the authority to put a hold on my vehicle and my car sat for a week in an impound lot,I am requesting
that I be reimbursed for the full amount of$337.49.
Officer Maloney 651-266-1111
Officer Hayes Badge 308 wBloomington PD
Rick Bowen my attorney 651-222-4614
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� Bloomington MN 554E31-3027
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Report N�tnl�er -- 1.���.{`.� ,'�'i�'t.�
O�aer Natne/Badge# '�-��.�u C'C'''°��C,.J S''
� :,'�.l?!' � Ttme af Report
Please keep#his form far future reference.If you receive
additianal infnrmat€on' on this case {i.e., suspects,
wimessesl,�l 952-563-49U0 between 8 am.and 4 g.m.
>Report reques#s will be procQSSed within 7-10 days.
There is a 25 cent per page charge for a capy of a report.
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C�IE:' e TONJZ:vG. IPI� .
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O�iNER: .:i�.. .,_ _ ��C.. .
HAWMAC7, REBECCA ��iZ�� =:": r�?�: =0; ._� ..�P''_'AP1Cc !'�?Rp
11354 XAVIEF. RD '':% ` - � .-`` "
3�OC!Pl:iqL011� i9�1 .`)`i��7 Sri�_.. ._ 'i , �-r'-. '`'��%��_ ;�
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' T�i� noLice is *o infor:nlre:ninci ;c_; . ;, �� •d;,�,: ° � _ - ! � _= t . _ . __;i in
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,, :r impound lot . Persuant tc hlf•i ,r =���-_ ,i-: _ � _ � _.:�
,n'. _.+�..,��..r ::;�.�r. .; � .:� �- _.. .. _,, _ . . � __- _.. .. .. . �-__ .. _ .. _.,_ __ _.- - . . _ . ... _._.. .
... . . .. �- �- �--' - - - - _ � r _.�.-� __
t�u have ( 951 days from ti�;e :la*e c` *.c . _�, . � _ � �.. _;ur v?hic -e and
��ontents . FULL PAYMENT rJF �H?�RG�S ;�?U°T �� C9A:?E .
Pailure to reclaim ycur vehicle .�+i�r,i�: : 45` :a:, 4�-:� be de?med
consen* to sell or dispose of th� vehic?e ar.� it ' s r_ont?nrs . °ersuant
to Mn Stdtue 168b . 08
' Vc�H?��� ?NFORP�]ATIO�: :
Niss�n SENTRF� s;2-�.°V . - _
T�WIiQG: 88 . �0 STOF.F.Gr : ; = _ . t)0 F.'-.�_:` ,i. �' - �
OTHER. TOW CH�R.GES : . �%i) . '� `�� - -
ADMZN eEE : 33 . 60 TAX : � - =+ '
' TOT:?� CUFRENT UUE : �9r . 9_�
I � v�u have sold th �_s v2hic�e p?°a;�- _ ta;. _ __ r�::��d� �` e .�tl�: rh,_
new ocaners i�formaticn so ��� _<�,� ac'.-;u>� , . � _ ; ��" .
Contact your ir.surance �ompar.}- _ _ * ":e•; .� _ �_ �..� _._ _ , fo� �h�= .._.-g�s
I � tney fail to p�ckup `ne ti;en=c�e • ' _ �;• , ... . � � � �- � _`o*_ _:,e
���!]dr4eS G�Ut? .
�ny and all ur.resalved :natters r?yard� ,c ! !�� : � e�:' -1F and tull paymenr.
3= the cnaraes will be :andlGd i .^. v^r.�i, ;a� i �c _< !: � - .
°'�.e venicle is be� na held at :
C`?i2i ' s "'ow�nu , Inc
851C }iarrie;, A�✓e ��c .
Bicc;ni::a�on , hiN 559�G
952 . 888 . �20�
..�n*ac� .:s ar��_ tc sa'_ _ .ia � ._ , : _ ,._ _ �-.. -. _ _ �n .;il'- t'e
_ _..�n �or ar,,.�.;r. ..s :ti�e� :�l�:s _ , .- - , _ .- .
STORAGE HCCR�.�S DAZL'{ u::T_� . ��!? -_.. .._ :. . �:'
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OLI�E D�PAR'��E���'�
TNIS V'EN
ICLE I� H� AVAILA�LE �El��r��'A�
�� TIL RELEASE RE UIREI�ENTS �A�'� I�E
UH
MEET
AHD C1i���' �01N�N�91N�: ��� ���H
HQTI�IE� BY TNE PO I�E DEpARTMEH�' a�� ��r�
ELEA�E
Y�OU MU��' ��N�A�T TNE P�LI�E,nEPAR'r��HT
TO OBTAIH VEHICLE RELFASE�INFORN�A�TI�N
� Bloomingtan Polic� D�pt.
� � ��ao �es� o�� �sr���a�e� ��. ,.
Bloomington, MN 5�i4�1 �
'�5�-5�3-4�00
Ti�is addendt���r to �ccomp�r�y c�rtiti�d ,�otic� ot impo���titneit�.
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. - � ; ��lEF`S TOWING, INC.
-%. • �� : . ' s3610 HA�RIETAVENUE SOUTH
Bl:�7f�MINGTON, MN 55420
PHONE (�52}8$8-2201 • FAX (952)'888-4944
DATE IN DATE QUT
NAME .
ADDRESS
CITY ', PHONE
YR. MAKE MODEL COLOR__ ; LICENSE# ___
� �� T1ME IN: � TIME OUT. � � ORIVER: TRUCK:
P.O.NO.: -
. �VIN q:� ._ ., . ".�.;.. .... .. _ _ __. .
� — � CASE 17: � . �� . .
- .. , .—. .__._ . .
R.O.NO.' -- _-- _ i�� �
_ � MILEAGE: . �
REQUESTEO BY MtIfS MlLES FREE T��S �__�����1 L��H�=T
__. -- --- Tp TOWED
' � - :.�� : — — - CHiEF3 T�taING I(VC,
..,�a._
' KEYS: �YES 8�1� tiHRRIEI HVE S.
LOCATION OF PICKUP: J{�p $Li�CfFSIN�TON, �iN �54Z�
, - TEftt�INHL 4�I�4�33
TAKEN TO: AMOUNT
TOW 84E�9525886
NOTES: 02/14iL013 1%:�8:1�
WINCH t�I`=;t=1
' �� xXRXXXXXXXXX�b7�6
DOLLY �it7Fi. ?Rr1NS. iG. 6�3�145509857�13R7•.��E ��
INUOIGE ���:�='v�ti� N�?2
ADDITIONALTOWING ��iTy_ ��p� ���:��. 7.7E1
ADMIN/FUEL FEE �j�� TDTtiL ���;� ° i•���
N!N'Sales Tax 7.275% CI i;;TE1i�ER C�°Y
' EXTRA CABOR
STORAGE FROM: @ DAY' #DAYS ,
�pVANCE PAYOUT TO_ �
�is��_ CASH CHECK CHARGE TOTAL
# " EXR i
I,THE UNDERSIGNED,DO HEREBY GERTIFY THAT I AM LEGALLY AUTHORIZED AND ENTITLED TO
TAKE POSSESSION OF THE VEHICLE DESCRIBED ABOVE AND ALL PERSONAL PROPERTY
TNEREIN IN ITS PRESENT CONDiT1ON AND AGFIEE NO FURTHER CLAIMS WILL BE MADE AGAINST
CHIEFS TOWING.
REGiSTERED OWNER -
SIGNED:
NOT RESPONSIBLE FOR NOT RESPONSIBLE FOR LOSS OR DAMAGE
TO CARS OR ARTICLES LEFf IN CAFIS IN
DAMAGE TO UEHICLE CkSE OP FIRE,THEFT OR ANY OTHER CAUSE.