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Kurtz '�.��'�D MAR 0 � 2013 NOTICE OF CLAIM FORM to the City of Saint P��i�sota Minnesota State Statute 466.05 states that "...every person...who claims damages fram an��municzpa[iry...shall cause to be presented to the governing bod��of the municipality wilhin 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 explain your claim,and the amount of connpensadon 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 r First Name �f� (.�l � Middle Initia )Last Name � (�1 �T � Company or Business Name Are You an Insurance Company? Yes/� If Yes,Claim Number? Street Address� � � � V U �"� �e- � �'� C- �`� ri� � I �� J City v a � �� 1� L�l � State �`�1 � Zip Code � � �� Daytime Phone( �� -.l��i 7Ce11 Phone( ) - Evening Telephone(E��1)Y-�' - ^�7� Date of Accidend Injury or Date Discovered ��1-{-� � �� 2 Time� (_) am/�m 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 iCs employees are involved and/or res onsi_ le for,your damages. �� r- u `✓'� , � � r�� o � 1l lAJ�� c" <�j v L �� o � v �ti �...,- - -I „� � r� o'��'� � ��` � G I Y�'�. . �� Jv2 �,_:.��?^.� G'`��' i^„ � , � ��+ �N �� ' '� �' ` 'W C� � � uJ c~ �^ yz lr. , � '�� r, �v,�' � S�t CQ,�� j � U i�� Q. �C�t? ' r � �� f/`�G � i�`, r' .y �, u^(l r ^ G.,� � 4� i M, �;1�, � G^ ,�. �. 1 � .r'r,� yv, 1 f �r h� ��r � ��^ �. t� �� s'� c� R � J� ��s� - � ��'<_' • Q -� �=tY"z�'i- K-v�� C��'��G,,,�.� i�-`2�,�i ��l�_ n,�.¢.'-� � cc.S 'T�W�� 1-�--j�c�,C f12t� ?.--h^�Ci� � ��`—�r,� J✓ i e.r��S. �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 vehicie was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow �'1C�y vehicle was wrongfully towed and/or ticketed ❑I was injured on City property ❑Other type of property damage-please specify p Other type of injury-please specify in order to process your claim You need to include conies of all apulicable 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. t'��roperty damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $�6.00;or the actual bills and/or receipts for the repairs �'fowing 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 atnd 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 witnesses to the incident? Yes No �Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes No � nknow (circle) If yes,what department or agency? �� ' �T� �- � ^ Case#or report# a,a- - ,��G i= r�vd'`�f{'.�2 P�,^�- Where did the accident or injury t e place?`Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detail as�ossible. If necessary,a�tach a diagram. �1�h,�� l 0�- �� 2 s�� .--r h. �s� w w�.�1 ��,��: �+-�� f �i s� E�.� �, Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim �t"o your satisfaction. M' ` � ` � �% � �r �%�r'� F =, � a—� ,. L � Q c S r'�'�� r� � G, �S� .� h u � �'n•c' G . G� �Q ��s' t✓e G i ��S ►r.t ltc��E ��v�d c: 1c� �` �y, �,'w�,�. . Vehicle Claims—please comulete this section C�heck box if this section does not anuly Your Vehicle: Year Make ' Model License Plate Number � State 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 complete this section �heck box if this section does not analv 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 Medicai Provider(s): i 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 informalion you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed '� . r 5ubmitting a false claim can result in prosecution. Date form was completed -� - -�- �-`� } �� Print the Name of the Person who Completed this Form: 'j � � � r>.�1�"'-E'L � - Signature of Person Making the Claim:�-�^� `/'\✓'� �� Revised February 2011 3/3/13 Claim Form f�` pl7Clt i �r�r :Claim Form "��' � o •Ung, Henry (CI-StPaul)<henry.ung@ci.stpaul.mn.us> date:Fri, Mar O1 2013 at 10:14 AM to: amicj@lycos.com<anricj@lycos.com> cc: Sanders,Donna (CI-StPaul�donna.sanders@ci.stpaul.mn.us>,Nelson, Kevin(CI- StPaul)<kevianelson@ci.stpaul.mn.us>,Mac�o,John(CI-StPaul�john.mac�o@ci.stpaul.mn.us> Dera Mr. Kurtz, I have checked with the plowing office and the information on the ticket, i conclude that t�tis'�ic�et�s invafi�.' I am sorry for tl�e inconvenience tt�at ou had to go through for the error caused by one of my taggers. •�-� . �;- - "�"`�"��rt�t��E�e' .- lease fill out this claim form and attach the towing receipt and mail it to the address on the fo�to get reimbursement. Please accept my personal apology for this incident. httpJ/www st�aul�ov/mdex.as�x?nid=186 https:/M�elxreil.lycos.com�wrn2/dri�er?nimlergeterrrail8action=print&fid=1NBOX&rrid=354438�shovulma9es=true 1/1 Saint Paul Police [mp�ound Lot, 830 Barge Channei Road, vehicle Release Form Make: 99 FORD License#: SB�,584 CN: 13036203 Invoice#: 20344 Date/Time Released: 02/24/2013 14:51 Tow Charge: $ 123.95 Released to:TOTO Storage Charge: $ 15.00 Y V" �� Paid by: CASH Admin Charge: $ 80.00 � �� Released by: JAMES Tax: (7.62�%) $ 15.55 I,the undersigned,have recovered the vehicl2 described above. Subtotal: $ 234.50 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 Impound Lot staff Total Charges: $ 234.50 on this form prior to leaving the impound lot. Damage and/or other problem: Police Report made:Yes_No_I�Yes, CN , If I�10, Wh� TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT 5/2000 Signature i � ! ♦ � ❑ O c� C) < � < � --1 N � � O 'a �w Z � S A' m-� � _ � O A � -,.m cn y. 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