Johnson, Ieshia tl 9 9e..V LL.m C V I..e v
�A�� 212013
,NOTICE OF CLAIM FORM to the Cit�i���'m'��ul, Minnesota
Mi�:nesota State Statz�te 466.05 states that "...every person...who claims danzages from any municipality...shall cause to be presented to tlze
governing body of the rnunicipaliry witliin I80 days after the alleged loss or injury is discovered a notice stating the time,place,and
circa�mstances 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 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���� Middle Initial Last Name �--_
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address���� ���7� ��C{� —
City State � Zip Code������
Daytime Phone (� - Cell Phone (�3) / �7[�Evening Telephone (_� -
Date of Accident/Injury or Date Discovered 3 Time—��`�`J Pm
Please state, in detail, what occurred(happened),and why you are submitting a claim. Please indicate why or how you
feel the ity of Sa��u� 1 or � s emp�oyees are involved and/or responsible for your damages.
Q T{�Q ��
Please check the box(es)that most closely represent the reason for compl ting 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•�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 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.
�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
O Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
andlor 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
Notice of Claim Form, City of Saint Paul, page two
All Claims— please complete 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 �� Unknown (circle)
[f 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 s detailed as possib e. lf helpful, attach a diagram.
�
�
Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction.
Vehicle Claims— le se com lete this sect'on ❑ check box if this section does not a 1
Yaur Vehicle: Year Make Model
License Plate Number �.J State�Color
Registered Owner `n��-� --
Driver of Vehicle
Area Damaged �T(�. �� a�� �-�
City Vehicle: Year Make Model
� k T icer.se P?a�e�`�u�r���r _ State _Color
�(�` Driver of Vehicle{City Employee's Name)
,�',��(�,�� Area Damaged
[n,jurv Claims please complete this section ❑ check box if this section does not app�
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 iniss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Einployer:
Address Telephane
� Check here if you are attaching more pages to this claim form. Number of additionaI pages
By sig�ii�rg this fnrni,you are stating thal all infnrmatiori you have prnvided is true and correct to the best ojyour knnwledge. U�isigned
.forms wi/I not he prncessed. Submitting a falce claim ca result in proseculioa.��. � �
Print the Name af the Person who Compl ed t ' �'or : � � IGi `���
Signature of Person Making the Claim:
�
Date form was completed Revised April 2007
I parked on the street near 432 Beacon Ave. Before parking I thoroughly looked at the signs to see if
there was anything saying no parking in which I did not see one.There were many other cars parked on
the same side of the street in front and behind me. I even looked further down the streets and cars were
parked at a long distance but still on the street. I live in Maple Grove and do not travel to St Paul. I have
never parked on the streets of St Paul. I know nothing about St Paul street rules or snow emergencies.
The only time I come to St Paul is during the State Fair on the State Fair Grounds which I park inside the
lot. I honestly didn't know that St Paul declared a snow emergency. I am originally born and raised in
Texas and I moved to Minnesota for school.When I parked my car there was less than 2 inches of snow
on the ground.The roads were clear as it looked like the snow plow had already been through. It was a
last minute decision for me to go to St Paul that night which was made about 11pm. I arrived in St Paul
about 11:30p or midnight. I didn't check the weather because it snowed earlier in the day and it was
what I considered to be not a lot of snow. I didn't see anything on the news about snow emergencies
but if the alert ran about 5:30pm on the news I would not have seen it as I was still at work with no
thought of even traveling to St Paul. Again it was a last minute decision to see a friend who just moved
in that same night from another state. He is renting a room for the school semester. He had no idea of a
snow emergency either or would not have known or seen the new because he was in another state and
traveling to St Paul MN until about 10pm which is the time he made it to his room. He again parked on
the street and received a ticket on his car. He or I saw no signs out stating no parking.There also were
no signs posted in that area declaring a snow emergency. Please consider refunding all or a portion of
my tow fees. Funds are limited at this time and the money I have dispensed on this situation has cost me
great anxiety and the lack of ability to pay other well needed bills. I support a five year old who depends
on that money. I did go to the violations bureau regarding the ticket and they handled it for me after I
explained the situation to them.They advised me to send a completed claim to the city of st paul for
further reimbursement from tow fees etc.
PLC Towing and Recovery
My car was towed by PLC towing and Recovery. Upon finally finding the snow lot I inspected my car
immediately before driving it away and myself and another person who was with me and who has seen
my car several times before the tow noticed that my valence/air dam was missing and a piece of it was
still hanging down in front of the car on the left side. I immediately notified the staff and filled out the
forms.They gave me the claim form and also told me this is how I can contact the tow company and the
city for reimbursement of the tow fees etc. I did contact Missy who then advised me of what to do next.
Thanks for help Missy.This was a very stressful situation for me and I think you were very nice and
professional in your approach.
leshia Johnson
� � �� r �
CusTOMER #: H135392
927.16
IESHIA JOHNSON *IN�rC ICE* �911 Lakelan� Ave N
9241 HOLLY LN N Brooklyn Park, �/IN 55445
OSSEO Phone: (763) 424-9100
, MN 55311-1276 Fax: (763) 424-5763
HOME: 763-442-6716 CONT: 763-442-6716 PA�I; 1 vww.kiaofbrookl �
BUS: 1 npark.com
CELL: 763-442-6716 ;:;�RVICE ,��DVISOR: 996_ �I SHANE NOF:R
< COLCQR YEAR NlAK��IFAOt7E�— - ••--�.--__._._
_ UI�J' ''
- ..__--__..^ LiC� is� Mu.�AGE IIV J 0UT
WHITE 07 SATURN E�URA __ 7,a� >
bEL. IJ;4T� p�iOb. DAT E U N A F t R. EXP. '.; fiFtCJM1��C� �_ .8ZS57Nt*_ ;.'F 1 7 1 9 2 1 V f�'N �
_. 60 114666 114666 336
_... ' �•G Ntb, ftATz : f�AYMENT:
OlJRNO'7 D -- .�- < INV. bATE
R.O.:OpEtvED 17: 00 04M��,I :I3
;REA[7'Y:j ;: OPTIONS: - `)LR:2 E;T1:3:3 . 5L V6 C�E� �T�AAH 04MAR13
11:57 04MAR13 12 :20 04MAR13
LINE OPCODE TECH TYPE HOURS '"''
A MULTIPQTNT UE.F3TCLE:; TIr3',SPECTT!�N � � , T�� �T NET
��"'�'�" TOTAL
CAUSE: MULTIPOINT VEHIC:GE INSPECTION
KCP2 MULTIP�TNT VEI-iICLE iNSPECTI�)�'3
1248 IPS 0. 00
w**ar�r�vrw**�ik'w�t�*�**w*�**�t�, �*�.*>��*w�i�***�c�*�i��k�k,� �*�*� �N/C)
B ESTIMATE FRONT VALANCE- `
�s;a To R�PZ�zaC� ��orr�; z�z�. �.�M/v�ir.��:� ,:r `
� �r���R
LINER $215 OR $150 JUST AIR L;��.'9 VALArfCI? '
I2�$< IPS O.iQp ' ,
PARTS SPECIAL ORDER-HUDSON- `' (N/C;)
; �s�*�*w*�:***�cw******�*'*�*�*� :r*****w* �t****���*!*�� , ****
_ _..., _ ... ._ , _
_..__._ ..__ ._ _ _ _ ._
__ _ __ _
_ _ _ _ _
fERMS:STRICTLY CASH OR CREDIT CARD ' pESC"tpTlpN ! T.OTALS ;
�ny wercanties on the products wa hereby are those maae ev�he m.3nufaeturer. �.s oetwem thk retai�ae��er a a� ��e-,cne C��:,MCPP LABOR �,IJI �UNT � . ��
NoduCt is to be sold'NS IS"an0'.'�entire risk as to the wy��'�a�Y°i pl Ed owartanty o���+EfChdnSBblli(y 0� t '�F%t� ' O _ O�
�xpressly disclaims ali warrant�ee �Nwr express of implied.�+c�udv+y �-7„
iarticula�pu@oSC,and the selle�'*��^!�assumes nor authenza v+r other peBU��o�ss�^`�fo�rt any 6abdity in c � w�m J`�ECURITY PARTS�>PA��JN O . O O
he sale ot said products. This�scw�mer by this sellm�n�a.Var affer.ts the te��+s of��e rt+a�utectureYS werrnn !.ouyer I��US GAS,�IL, l.�BE
�ck�o.+�ed0es beino sa��fnrme�onor to the sale. NOTIC£:Aii oarts new origina��autiome��un'ess otherwise specif�C I—,l��THER SUBLET P h'�>UNT � • ��
9 herebY suthorize the rooeir m v hlcle oltertleles left x�veh cle n�ur'e of from�.n our o her�c'we�a baY�rh,'.��+.�'��.��ed or L J MISC. C H 4 �3ES" O . O O
�esponslble tor bss o�dama9< , --� "_
lor anV deleV6 causad by��'VebNity of parts or dN�vs in p�rts���.menfc Dv Me vo��or transDOrter.I h���•�� ;��r�t you O . O O
nndlo�vour smployees Dc'""+'�to oDe�ate ihe vertic�e huN^3esc'"��a°ede��°t��`��°o Iseeurch thefamc'�e�.'���+x��aa�n TOTAI�:F�F iGES
rosHnO�dlor insPecfion �.mxDreu msCM1w�IC's lien n^�'�r ack+w+ B
' RENT:AL CAR -- 0 . 0 0
theret_ o.�__�— O . O O
L..)YES SALES'rF�Y
PIEASE P,'.Y '
X -- •--- [] NO THIS P,,d7c iJNT 0 . D�
------ - - nd��� �`���
CUSTOMER SIGNATURE ` �
s,carburetor deaner,
i�. ��s��ltler,battery clua����r,wire,window ueler,etc. '
�MISCELLANEOUS SUPPLIES ANDrMP�EPafot anA mate9als.shelacawwen�teroia91s and/or hazardous r�T';�� sa�lif app�iceblal uaed oo Your vehicle.Materiel t-+n's _
are:Nuts.�0l[5,
wa5hers,taPe.Pi ...��..n•....,,�+nr� /�/'�7'1'V"
�d:'�'�c�°t�vroii�d�'be =:��w a���
�° �i�
Customer Name IE__ g_ H�q�iRR�CE JOHNSON
Consuliar�it Nick BIG;ner
Warr CampanY '---------_ =-------._
�- ��.c�ntract# 763.^e2_.1905 ext 3
Phone --------_.._______---._.
�-' F2x
Adjuster ----._.___ _________
�'- '�'sar Make A9p�r.le�
RO# _._.
__ -_______-
`-- t'�ental Days�$30
��, � '_' ______._
1 BUG SHIELD DEFLECTER � �����x: ^ " � � � �,
2 $e�.ss � '�i� � �Il !Wa�������1�"�� ' �,°
�'-5 $65.00 �
3 - a $0.00 -_ $152.93
,q ° �.. $OA�
5 _ ..._ ._.,. $0.00 �_
- $0.00 ' $0.0)
6 ...__
� . _.i......_, ._.. $0.00 -- $OAi)
t .. .. $0.00 " $OAf 1
�., � , �
$ �;�.,���!:; , $OA(i
10 -I-._.. _ $0.00 --
11 _....•-, ._. $0.00 _ $O.00
$0.00 $0.00
12 _ .. -"' $0.00 __. $0.00
13 ._....
$0.00 $0.00
14 r "�`;'�.r, � $0.00
15 _� , �� �. ,:� : ` � $0.00
��� �:` �::�.` , '�� ,, $0.00
17 .._ . $0.00 � m�� . $0.00
18 .__ - ..__ ._..' $0.00 •-- $0.00
r $0.00 $0.00
19 - _ ...._ _'i $0.00 •--
20 __.. �-,� $0.00 __ $0.00
$0.00 "! $0.00
i�M� $0.00
�
• ' - $87.93
Part# Desa �� : ,�,;r'' �� .�. $65.00
PARTS '�'• �f`�i" cr'^ $0.00
�i� I� r , $0.00
LABOR __ � ,
'1� p;; $25.00
TAX ._ r���
RENTAL �' �� $6.40
.. �i� , $O.00
DEDUCT _ .� �^ ` I� -�t $0.00
TOTAL ,4p.pp �yj
a�l $0.00
�_ ��r� $184.33
,
1 _ . ....-
; .
� _._......_.
�hevrolet wa��="�th:�t for a pern�c''2 monihs after=ti� ; c�f a new replacem::nt Parts and Accessorie�'o •r-the-
counter",or w��'?2 monms��'�.:��%"�s whichevw ro s c :�r,,after i�tallat+c•n thereof by our tlealershi.��x motor
,ehicle,it wili�r�r furnish a��Part���"!`��� �'o�maHunction�xj F�art or accessory.This w:+riar i i covers
rry repairs x�ec�*'�ma��5 k 1 I,i�to cletects in menerial or vrorkmanship.
) �n=1
, - - .. . .y., .., �,..�„��� �,�du, u E�� �cie Nelease F��rm
Make: 07 SATURPJ License # �,�I=
_M760 CN: 130362!?3 ' '
Date/Time Released: 02/23�2013 02:27 �
Tow Cl�;�r �e: $ 123.9:�
Released to: TOTO
StoragE� � iarge: $ 0.00
Paid by: CREDIT CARD
Admin Gh.�rge: $ 80.00
Released by: MAI C►ER
Tax: (7.ti.:': %) $ 15.55
I,the undersigned,have recovered the veh�c4; described a�>ove. Subtotal:
I will check the vehicle for damage or any �#�f:,�r problems �hat
may have occurred ivhile this vehicle was ;r� I�ie custod ai the � 219•50
Saint Paul Police Department. I acknowied�,r�: 1 jaili repoi�t Service C;h. -ge; $ 0.00
damage and/or any c�ther problems tQ the Irr�r��nd Lot stai'f Total Char� s: 2
on this form prior to I��aving the impound lot.
$ 19.50
Damage and/or other �� � ' . �
� ,; _ .F� ,
o • �. . .
_ ,
pr em. t , f � , d,� ,� �,, ���
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+ , � �.y ;� f, ,� �} , .
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�.« � ! �� j� ";r / � � �
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' _ �- ���; �(. >'-
---___ , -
_ _ ______
------
Police Repo made: ti'es —
� _No_ IF Yes, C I��;.-- _._ __, If NO, Why%'--
TO PROTEC YO�' R RIGHT REPORT AN'� !::?ROBLENlS�'DAMAGE BEFOl3 : L
Signatu`r�e
J ! t � � __ _ EAVING THE LOT
. �
` ___..,_..
___- '-_._.__
-- ____ 5/2000
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