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NOTICE OF CLAIM FORM to the City of �aint��a���1Glinnesota
Minnesota State Statute 466.05 states that "...every person..:who claims tlamages from any,municipaliry...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 a�nount 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 �Shu0. Middle Initial J Last Name CouY
Company or Business Name_�/1'
Are You an Insurance Company? Yes/ i� If Yes, Claim Number?
StreetAddress �� {'t, .Y�S �St' �
City �i�n.t�Ot.t�l,` State M1J Zip Code Jcs l c7
Daytime Phone(�i�)2� - °5 3� Cell Phone(�b�)?�.- oR r3 I Evening Telephone(7�Ws�)�-�
Date of Accidend Injury or Date Discovered?.�1�!� Time 2�35 ar /pm
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 its employees are involved and/or responsible for your damages. Mv caY w us towed
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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
�y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ ther type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all anUlicable 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
�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 yoor 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 comnlete this section
Were there witnesses to the incident? Y� No Unknown (circle)
Provide their names, addresses and telephone numbers: �lirv� L,vorSol� (al2—z5�—g�{9�'
Were the police or law enforcement called? Yes � Unknown (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.
Go�t �n � on -�e � e(�
G oY m.a n. �-vc,
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. 1 aw. Sge}'i►w► 2.19 � o •r ,�rr.. uxTe��n ul �,P
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Vehicle Claims—ulease complete this section ❑ check box if this section does not avvlv
Your Vehicle: Year 2.oblp Make �c.c.�_Model G rn,v`� G� p_ro��
License Plate Number 5� - CC� State�Color b�ur�
Registered Owner u.r
Driver of Vehicle Jo�lna.�.q �.awY'kv►� �
Area Damaged N/E4-
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Inlurv Claims—please complete this section .�check box if this section does not apply
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))
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 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�� �1�
Print the Name of the Person who Completed this For : Jash� �A f
Signature of Person Making the Claim:
Revised February 2011
� Saint Paul Poiice Impound �ot, 830 B�rge Channel Raad, vehicle Release Form
R�ake: 06 JEEP License#: 550CCC CN: 13027844 Invoice#: 18611
Date/Time Released: d2/11/2013 20:10 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00 �� Y v`�
Paid by: CREDlT CARD Admin Charge: $ 80.00
Released by: MARTHA Tax: {7.625%) $ 15.55
I,the undersignec�,have recovered the vehicle describe� above. Su�total: $ 219.50
I will check the veh+cle f�r damage ar any other problems that
may have occurred while this vehic!e vras in the custody of the Service Charge: $ O.OJ
Saint Paul Police Department. I acknowledge I will repert
damage an�+lor a��y oCher problems to the lmpaund Lot staff Total Charges: $ 219.50
on this form prior to leaving the imF�und lot.
Damage andlor other problem:
Police Report ma�e: Yes�No_IF Yes, CN__ , If NO, Why?
TO PROTECT YOUR RlGHTS, REPORT ANY PROB�EMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
�-� , -• ' Citation#
.
- - • ST. PAUL HSS ?4y °� ��
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STATE OF MINNESOTA-RAMSEY DISTRICT COURT III IIII)IIIII IIIIIIIIII IIIII IIIII IIII IIII
I IIIIII IIIII II
The undersigned, being duly sworn, upon hislher oath deposes and says. * $ 8 g 7 q. g 4 3 2 *
Date of Offense / � Time of Offense '
Plate
Veh. License Na Year State Make Style Color
Location of Offense:
VIOLATION: SNOW EMERGENCY St. Paul Ordinance 161.03 FINE $53.��
(Amount includes mandatory state surcharges of$13A(
CN .. .
Gitin Officer Citing
C�fficer Number Dept.
❑Posted Night Plow ❑Day Plow ❑Plowed in(Windrow) ❑Tagged Before Plow ❑Drove O
OFFICER'S NOTES
❑NO PLATE VIN:
�itation can be paid at the Impound Lot.Please read the back of the citation for payment instructions.
CITATION
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r O�tlook Print Message Page 1 of 1
claim form
From: Ung, Henry (CI-StPaul) (henry.ung@ci.stpaul.mn.us)
Sent: Thu 2/14/13 1:22 PM
To: joshua.j.courtney@live.com (joshua.j.courtney@live.com)
HiJosh,
1 found the ticket. I will dismiss the ticket. However,to get reimbursed for the towing charge,you need
to fill out this form
and attach the copy of the towing charge and send it to the address on the form.
http�//www stpaul.gov/index.aspx?nid=186
Henry Ung-
Ordinance Enforcement Supervisor
Public Works Right of Way Section
651-485-0414
https://b1u002.mail.live.com/mail/PrintMessages.aspx?cpids=e0ba77ab-76db-11 e2-9209-00... 3/9/2013