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RECEIVED MAR 15 2013 NOTICE C�� CLAIM FORM to the City o��lj� 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 vaill 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 completed. If something does not apply,write`N/A'. r.--.., SEND COMPLETED FORM AND OTHER DOCUMENTS`��'(j:�CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name�(��' 1 '� Middle Initial L' Last Name �U�. ' Company or Business Name �`�'�� Are You an Insurance Company? Yes No If Yes,Claim Number? (��� Street Address � � � S Li v t c�o n ,�V;(k � ��-- I City ��fi � �C� �� State �� Zip Code S �� � Daytime Phone( �,� Cell Phone '�-�-') �-`��= //�� Evening Telephone( � ;,�,� Date of Accidend Injury or Date Discovered �-) I I I 1 � Time � am pm i Please state,in detail, what occuned(happened),and why you are submitting a claim.Please indicate why or how you ! feel the City of S 'nt Paul or its employees are involved and/or responsib e for your damages. I � � r � 1 ( 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 copies of all auplicable 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 WII,L 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 Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt 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-please complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telepho mbers: 1� j��-e�rtr��C �« �;�s� �5�� � ��.�v� S ��� �n� J��yh� �u>> ��u ��3�Z (��,�ou �.r�� 2ti�-,t:r,��,� �e � � S+� �-�, n�r��-��c�r� Were the police or law enforcement called? Yes (�T�o ) Unknown (circle)C�'�� ���" ' ����� If yes, what department or agency? N`i k �-�Case#or report# N�A Where did the accident or injury take place? Provide street address,cross street,intersect n,name of park or facilit}, � closest landmarky, etc. Please b�e a�s�d�eta�iled as possible. If necessary, attach a diagram. �- ��'��-�'� dr��'` �� ��...Li t'�(l�(+ i(� � 1.�!�',Q�r 1 �(l�.Y`'.P C`t'lv w���—j n V��l�t�v"x 3 C15 IM n l�f�_ � Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to vour satisf�ction. ,�� � � � pl_1„ " �l �Wl�C�.,..`}c.G# �_ _ J � - - y- . Vehicle Claims-please complete tlus section �heck box if this section does not annlv Your Vehicle: Year Make Model_ License Plate Number__ , State_ _Color � Registered Owner . ' Driver of Vehicle J � Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims-please complete this section `icl check box if this section does not annlv 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 j 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 fornz,you are stating that all information you have provided is true and eorrect to the best _ of your knowledge. Unsigned forms will not be proeessed. n Submitting a false claim can result in prosecution. Date form was completed �I�� � � Print the Name of the Person who Complet t'Form: 1�_(����-�- �� b��� Signature of Person Making the Claim: � Revised February 2011 L% On February 10`" I called the St. Paul snow emergency number(651-266-7559)which declared a snow emergency with the rules stating that north-south streets with night plow signs are the night route starting at 9pm. Then starting at 8am the east-west roads are day plow routes. At the time of this snow emergency these were the rules stated in the voice recording on the snow emergency number and online (which I see they have now changed). Since my street is a night plow route, meaning it's a north- south street, I went to the first intersection of my road(Scudder St)which is perpendicular to my street (Gordon Ave). I took a right,and because I am a person that double checks things(especially pertaining to something that would cost my just shy of$300), I paid attention to see if there were any signs pertaining to snow removal,which there were none. I found parking on the left side of the street so I turned around in my ally way(which is before the Como Ave/Scudder St. intersection)to face the other direction on Scudder and park,again no signs. This side of the street was nearly filled up with cars at 9pm,which I believe indicates that many people were misled and unaware that this side of the street was an exception to the standard rules and was actualty a night route. As I walked up from my parked car to the intersection of Scudder and Gordon,the only sign visible was a"no parking sign from here to curb",where normally a night plow route this side of street sign is normally posted. Given the fact that it was addressed online and in the voice recording that day routes are not marked,and the fact that Scudder St. is perpendicular to the north-south night route street I live on (Gordon Ave.),this gave me the okay that I was legally able to park on that street during the night. On my street,Gordon Ave,which is about the same length of the Scudder St. between the intersections of Como and Gordon,there are two night plow marked signs near the intersections on Gordon,which seems to be the standard city practice of marking streets. I looked at the intersection on Scudder and Gordon,where the signs have been posted,yet no marked sign was installed. In my defense,there are plenty of"no parking" signs if I were to take a left onto Scudder Street from Gordon. At the time of this snow removal, in the voice recording and online there was no information provided about the exceptions to the standard rules of north-south=night route,east-west=day route. Online and in the voice recording they now address these exceptions and more detail pertaining to the standard rules,which I believe show that these were previously misleading, inconsistent, and poorly stated rules. Due to the inconsistency of the snow removal rules and the poorly marked signs of exceptional roads I feel that I should not be subjected to this cost, let alone the cost of my time,due to the lack of the city doing their poor identification of the snow emergency marked signs in St. Paul. � � c�' �� �� � � � X � � �� — � � � J � c� ' r--------�, � �v��� � a i � ����� � .'� � (�(k�;��� � � _-� , , n �, �1 � r��- � � I"� ���L; � C��I�i �'u,k'r� �-I� CG r,,�. I `� P `� . , Citation# $�8 "���.�'�'� . �. ,'� ST.:PAUL � • 'f ^ STATE OF MINNESOTA-RAMSEY DISTRICT COURT - ��I���I���II`�����I,���IL���1��'� :: The undersigned,being dulyswom,upon his/t►er oath deposes and says- �� * 8 8 8 7 5 4 6 7 8 * Date of Offense � � [ � �� � Time of Offense L ' C.��� Plate L-��{- Veh.License No.� ) f?��Year�State � � Make �� � ��� Style_ '�-/F Color � Location of Offense:�l.� � L'l-�`�'""� J����.•� ��1 � t�/ � ��i r�V � VIOLATION: � SNOW EMERGENCY St.Paul Ordinance 161.os FINE $53.�0 (Amount includes mandatory state surcharges of$13.00) CN � � e��� �� � � Citing Officer � � t� Citing � Officer Number Dept. ted Night Plow � ❑Day Plow Plowed in(wndrow) ❑Tagged Before Piow ❑Drove Off OFFICER'S NOTES ❑NO PLATE VIN: Citation can be paid at the Impound Lot.Pl�se re�f the back of the citation for payment instructions. CfTATiON Saint Paui Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 00 TOYOTA License#:445PD8 CN: 13027844 Invoice#: 18910 Date/Time Released:02/11/201312:30 Tow Charge: $ 123.95 Released to:TOTO Storage Charge: $ 0.00 Paid by: CASH Admin Charge: $ 80.00 Released by: ELISE Tax:(7.625%) $ 15.55 I,the undersigned,have recovered the vehicle describeci above. Subtotal: $ 219.50 � � I will check the vehide for damage or any other problems that � may have occuRed 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: $ 219.5d 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 PROBLEMSlDAMAGE BEFORE LEAVING THE LOT Signature 5/2000 . �� � � t" .. =` . �• .� 11l � � �• Y �'f�i't �Ji � �)". 7��'j � {!� r,.*"�, ��':%d��i P�1'�� �,i 4 `� ,���t , �a�� i°s�� ,� �s � �t �'t,�+�+i��,r� , i� ;� � .< ; �� � � �; � Fd,, .'� .ti f, �� :,0 Y. �t' +' ��� � � .. � �, P1� y� , �► ,r,,, . - . �,, ,�. - ~' Y�� �� �� /' ' . - ,: :� . . ;�; , , , � , �, ,,� , ��. � ,.� F' ` `1, � t� �6 �`�, �T � • „ •• '' ' � � i '�1� � !/ � �` �@��: ��c � , ( �.,a� .�.�, �y�t's �-�. , c � �, .a'�: . —, �' �; + ,,,�,ryNa �.P''� � '���/���."-'�Jf� � ,� :� �:� • �:\ : l,��s�v;�l. ..v.i; n f. e+r �r�' ��f� ,.,.. _,� N ,� ��+,,� v�' r`? .t . �,y � � �" �.�`.> � y/�1 9!f_ �,,°,,.ttt3���� ��a�������� �� i ;�� �/,� f-q"tf'i,. 1 r t- �`�l� 1� p �� . .�� �_-:.+ .,C: _i� `d�'-.s� -.`. � r1 !' 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