Loosen ' RECE►VED
NOTICE OF CLAIM FORM to the City of s�i�tBP��, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages jr��n�n(un�t��cause to be presented ta 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 nr 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 � �`�'`'}""�` �o"u'"�Middle Initial � Last Name '�"�'`�'
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address a��Z �} �'`�` 5
C1Ly �'1�l.lw�n L�.i ,7� � �7
State M� Zip Code `��y� �
Daytime Phone( G iZ) G�� - G ►��I g Cell Phone(��Z ) G�L- �'`' �g Evening Telephone( ) -
Date of Accident/Injury or Date Discovered � '�'� ��3 Time ��' S � 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 its employees are involved and/or responsible for your damages.
4,c- ���u 1�.�Z a .
Please check the box(es)that most closely represent the�reason for completing this form:
❑ My vehicle was damaged in an accident O 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
�ther type of property damage—please specify `Y��- •+ ��� ��
�❑ 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 incly�de the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and b�come 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 esCimates for the repairs to your vehicle if the damage exceeds
�$50 00; or the actual bills and/or receipts for the repairs
Towing claims: legible copies of any ticket i�sued 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 i[ems
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 comulete 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 Unknown (circle)
If yes,what department or agency? � ��.�. yt� �� Case#or report# ��' — �� ��' �}`'Z
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. � ��°��
�G vi.e�.r �..,k{r c y►.�, C k r !^l• � -�o wc-L tv�w<< ;-� i..ri�' S'�'d�c-•�
Please indicate the amount you are seeking in compensa�tion or what you would like the City to do to resolve this daim
to your satisfaction. `I� 1 I o . U �
Vehicle Claims please comulete this section �check box if this section does not apnlv
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 Natne)
Area Damaged
iniurv Claims please comUlete this section �1'check h�x 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
,�heck here if you are attaching more pages to this claim form. Number of additional pages �. �
By signing this form,you are stating that all infor»rccation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be prdcessed.
Submitting a false claim can result in prosecution. Date form was completed �/�'��
Print the Name of the Person who Completed this Fo�m:
�l�� v. ���� L a 6 �.c..�
Signature of Person Making the Claim:
�r. —�—.
Revised February 20l 1
4/5/13
Reason I am submitting a claim:
My car was stolen, and reported stolen, which you can see from the atta.ched
Minneapolis police report. While in the possession of the car thief, my car
was towed during a St. Paul snow emergency. I am submitting the claim
form to the city of St. Paul not beca�se I feel it was unjustly towed- I have
no idea if it was unjustly towed or not and assume it was towed leggally, but
I am submitting the claim to recover the administra.tive and storage fees I
had to pay to retrieve my car from the impound lot, due to no fault of my
own. ;
I am willing to pay the towing fee of$54.50 as I assume that it was towed by
an outside vendor and not the city o$St Paul, but I am seeking re-
imbursement for the $30 dollar storalge charge and the $80 dollar
administrative fee ($110 dollars total reimbursement). I had my parking
tickets that were accrued by the car thief during this same snow emergency
waived once I showed evidence my car was stolen by the city of St Paul, I
don't see any difference in getting these similar administrative fees waived.
Thank you for your time.
Theodore Loosen
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Saint Paul Polic� impound L�t. 830 Barge Ghar�neE Road, Wehic(e Reie�se Form
Make: 92 HONDA License#: TLG�Ob ' GN: 130377t7 Invoi�e#: 1A316q
Qate/Time Released� 02126/2013 17:52 I Tow Charge. � 54.50
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Reieased to: OWNER ��tflrage Charge: � 30.00 _
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Paid by� CREDiT CARD dmin Charge: $ 8Q.40 �
Rsleased by: PER�ITA Tax: (7.625°l0) S 10,26
I,the ur�dersigned,have recovered the vehfcle described abc�ve. Subtotai: $ 174.76
i�i11 c�eck t1�e vehicie for damage ar any other prvb�ems Chat
may have occurred while this vehicle was in the custbdy of the Service Charge: � 0.0�
Saint Paui Pc�lice Department. I acknowledge i will r�pc�rt
damage and/or any other prabiems to the impaund L,ot stafF Tatal Charges: � 174.76
csn this fc�rm prior to leaving the impound 1ot.
Damage andlor other problem:
Polrce F2��orf maCe Yes�No�IF Yes, CN , #f IVfl: Why?
T�PR�TECT Yt�UR RiGHTS REP�RT ANY PROBLEMSlQAMAGE SEFORE LEAVING THE LOT
5/2Qfl0
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MPD CAPRS Case Report With Supplements - MP-13-047742 Page 1 of 3
Case Report with Minneapolis Police Department CCN: MP-13-047742
Supplements
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Report Details
Reporting Officer: 001087: Derek Chauvin Approval Status: Approved
Assisting Officer: Approval Date: Feb 18,2013
Supervising Officer: 095704:Christopher Hudok Date Returned:
Approving Supervisor: 095704:Christopher George Hudok Return Count: �
Call/Sqd: 362 Date Printed: Mar 14,2013
Precinct: 03 Last Uploaded: Feb 18,2013
Related CCN : -- ;I Solvability: 45
Reported Date: Feb 18,2013 19:21 Primary Routed Unit: 4037-Pct 3,tnvestigators
Entered By: 001087
Incident Details
Offense1: AUTOTH Desc: Motor Vehicle Theft I Statute: 609.52 Attempted:
Address: 2912 37 AV S
MINNEAPOLIS,MN 55406
Occurred From: 02/14/2013 20:30 � Dispatched: 19:04:00
Occurred To: 02/18/2013 18:50 Arrived: 19:11:00
Location: ' Cleared: 19:45:00
Minor Involved: No
Public Data
OFFI�ER SPOKE TO VICTIM WHO STATED THE LISTED VEHICLE WAS LEGALLY PARKED IN FRONT OF THE ABOVE
LOCATION. VICTIM STATED THE VEHICLE WAS PARKED ON THE LISTED DATE AND TIME. VICTIM STATED HE REALLY
DOESN'T PAY ATTENTION TO THE LOCATION OF HIS VEHICLE WHEN HE IS NOT USING IT. VICTIM FOUND THE
VEHICLE GONE TODAY.�VICTIM STATED THAT HE HAS THE ONLY KEY AND NO ONE ELSE HAS PERMISSION TO DRIVE
THE VEHICLE. VICTIM STATED THERE WAS NOT A SPARE KEY IN THE VEHICLE AND THAT IT WAS NOT
REPOSSESSED. VICTIM ISSUED A MPLS BLUE CARD. AUTO DESK NOTIFIED.
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https://caprsweb/CaprsApp/CaprsReport.aspx?GUID=b 1 f07579-8b5c-41 ab-b027-e9aea90a23d8 3/14/2013
Iv1PT� �`AFR,�� C'as� Rept�rt With Sugpl�ment� -?�1P`-13-44774� Pag� 1 c�f3
Case Repart with 1�Iizrn��rpoii� Pol�c� Depactment CCN: MP-13�U4774�
Supplement,�
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Report Detaits
Reporting Officer: 441087 Derek Chauvin Approvai Stat�: Approved
Assisting Officer: aRPravai Date: Feb 18,2013
Supervising Officer: �95704:Christopher Nudok OatE Returned:
Appraving Supervisor. 095704_Christopher Gearge Hudak Return Count: �
GalUSqd: 382 Date P�inted: Mar 14,2013
Rrecinct; 03 'I Last Upioaded: Fets 18,2013
Related CCN: -- Solva4iiity: 45
R�port�d Date. F�b 1�,2013 19�21 Primary Rau#ed Unit: 4fl3?-Pct 3 Investig�tor�
�nte�ed By: 001087
�J1CI{�@('Et D@t31�S
Offertsel: Atl"tC3TN Desc: f�iotor Vehicie Theft I Statute: 6Q9.52 Att�mpted:
�d�dres�= ��12�37 RV 5
PAINI�t�AP0�.i5.hAN 5540�
Qccurted From: 02114l20t 3 20;34 � Dispatched: 19.44`00
CTCCUrr�tl To: 021�812tf13 1�:517 ARived: 18��1�00
Location: Clesred: 19:i5:00
Mtnorrnvotvea; ��
Public Data
QFFiCER SPOKE TU VICTIM WHC7 STATED THE LlSTEd VEHiCLE WAS LEGALLY PARKEE}!N FRONT OF THE A64VE
LOCATION. VICTIM ST`A7ED THE VENIC�E WAS i'ARKED OtJ THE LVSTED C}ATE ANa T1M�. V1C7fM STATED HE REALLY
pp�SN'T PAY ATTENTi�N TO THE l4CATiON OF NfS VEHIC�E WNEN HE iS NOT USING IT. VlCTIM F't7UMD 7HE
V�H(CLE GONE TODAY.VICTIM STAI'�C3 THAT HE HAS THE C}NLY t�EY Af�C? 1Vt)Ci�IE EI.SE HAS PERM15SlC}1d T'C7 DRIV�
TFiE VEHICLE. VICTIM STATE[�THE�t�WAS hIOT A SF'AFtE KEY iN 7HE VEHiCLE A�JD TFiAT IT WAS NOT
REPQSSESSED. VICTIM iSSUE�A MPLS BLUE CARb. At�TQ DESK NUTIFIED.
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1�1PD f'AI'RS Case Report Va'i"th Supplen�ents - 'vtF-1 3-0477�2 Page? of 3
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Victim
Role/Rale#: ���1
Name: Loosen,Theodore Michae!
Residenca: 2912 37 AV S
MINNEAPC)lIS,MN 55406
Telephone: C 612-616-8598
Drv LEc!F: MN E75506501351?
Date of Birth: 09J05119?8 Event Age:34 Est.Age:34-34
Race: V+fiite
Sex: Mais ',
Height:
Buitd:
Victim of: AUTOTN
Suspect
Role!Roie#: 5001 II
Name: Unknown
Reside�ce: Unknawn
Telephone:
Date of Sirth: Event Age:4 Est.Age:4
Raoe:
Sex:
Height:
Suild:
Relationships
SUb1@d Rg,l Cta onsrilD TYAB bb�e�t
V001 Loosen,Theodore Unknawn S�1 Unknown,
Modus Ope�andi
Ca o De�.cr°,�tior� Rei�d Uffense omrn n
Crirne Elements ��+g�
Crime Location Auto
Crirr�Lacation SlreeVSid�walk
Griminai ACtivity PossessinglConcealing
__ _ . . . __ _. .... . ._ . _ __ _._. _....
Vehicle I
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Vehicle Number: 1
Owner Role: V001 Owne�Name: l.00sen,Theodore
�ke; Honda Modet: Civic .
Model Year: 1992 VIN#: 1 HGEG8547NLQ42555
Ptate: MN TLG100 Plate Year: 2G13
Estimated Value: �� a�
Yehicte Sratus
a o date [}escrration
Vehicle Stalen Y�
Vehicle Descriptlon
https:/leaprsweb/CaprsApp/CaprsReport.aspx?GUID==b 1 f07579-8b5c-�1 ab-b027-e9aea90a23d$ 311�J2013
MFD CvAPRS C`ase Re�art With Su�plements -'v�P-13-047742 Pa�e 3 of'3
Cateaarv D�scriptian Comments
Vehide Color Side Grey/5iwer
vehide CotorTop Grayl5iNer
VB�TiCI@'Ty� d dOOf
Case Suppiements
There are no suppiements for this case.
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End of report for case MP-13-047742. P�int IQ: b1f07579-8b5c-41ab-kr427-e9aea80a23d8
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D�PARTM�NT OE POLIC�
7'homas I"s.`.it�»th,("hief nf Aaticc
CITY 4F SAINT' PAUL .il�?Grr�uv5trt•e� Teleph�»re:b5!-?91-6QGS
C«hristApher�.Caloman.9�tayor S�.Paul,14linrre.maa 551(11 Fae.rimile:6t7-?66-5;11
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CERTtF1ED Nt3TIFICATtON LETTER �
STATE C}F MiNNESOTA
RAMSEY GOUNTY
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;��t� ���t ;;��;�; U2I�612(J13 C g'•�: 1303771 i ��6�' i c�';;=�=�": t�2,'241201a
�����r � �;�:t�>�,,��� MEC'HA:NIC, t442 �d'.I.t��i.: �HGF�G�547NL042555
=°�1`���r L� ���� �;#�n,�: 92 H(�NI�A (...i�;����=: ��s. TLGI00 �'t�t�: MN
O�,�r€�r: I.<onsen, Thec3t�c�re
� 2912 �7t��v�; �
� Minneapolis�tn 5340�i
,���;�;�e I�3160
The ab�ve listed vehicl�, in whic�you hav�a property interest as the awnerr'lien halder, has been irnpnunded by
the Saint Paul Poliee Departrnent,in accordance witla City Legislative Code Chapters 161, I62 anc� l b3,
Minnesata Statute 168B.(J4, or other a�plieahle law. This vehicle was towed to and is bein�held at the I'olice
Impatind Lc�t, �3Q B�r�,7e C'hannel Road, St. I'aul, �innesota 551(l?
C'lazm�Vehi�l�
Under Minnesata Statutes 168B.OSl, 168B.07, & 16��.��,y�u havc tl�e right t+a reclaim the�.3ehicle. Also
pur5uant to the abc���e statutes, you may hatre the ri�ht ta re;ciaim�ro�erCy fram the vehiele.Failurc€o�;�laim
the ve1��41� and�'c�r its eontents within the apprapriate tim� altowed and ur�der the c;onditions set forth in the
�� gc�vernin�statutes canstitutes a w�iver o�all ri�ht,title, and int�rest in the vehict� and its �c��aten�. Piea�e�e�e
the artaehed infprmation for perTinent statute languag�.
�
If claimed,the vehicie and��or its contents will be r�easec�to yau upan satisi�actary evidence of aw•nership,
inst�rance and pay�e�t of a11 tawing,ac3ministr�tiv� fees. storage #'ees �nd tax.
If you da not clairn the vchicle ancLfnr its con�ents within I 5 days after legal notice tt�the awne;r, it is cc�nsidered
a waiver hy yau c�f all ri�;ht, title. ar�d interesf in tY�e vehicle andlar its Contents azld cc�nscnt tn th�Lransfer of title
to anri cii��vsal or saie of the vehicic and/or its co�tents under Minn. Stat. l 68B.(}�. The Ciry will dis�ase ur sell
dny uncCaimed vel�icle anc�Jar contenYs. Per Minnn. Stat.§ l fi�I3.0�1 Subci. 1 & l a.
AA-AI3A-E6t�Gmpl��yer