Sauvageau RECEIVED
�pR 2 9 2013
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
C�ITY �LERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...sha cause to e 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 will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and�he amount of compensation being requested. You will receive a
written acknowledgement once your form is received. T e 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 C�ITY HALL, SAINT PAUL, MN 55102
First Name Zachary Middle Initial � Last Name Sauvageau
Company or Business Name N/A
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address 2314 Broadway
City Fargo State N� Zip Code 58102
Daytime Phone(701)281- 7352 Cell Phone( 701)541-6048 Evening Telephone( 701�541-6048
Date of Accident/Injury or Date Discovered 02/11/2�13 Time $��� am/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 em�ployees are involved and/or responsible for your dama es.
At around 8:00 on the morning of F-ebruary 11 th, I went out to move my car which was pa�ed ou si e o a nig p ow
zone to an adjacent street so that the plowing could continue. When I went out, I discovered that my car was towed.
My friend had been parked directly behind my car, and he was not towed. I called to the city and confirmed I was parked
leqallv As I was parked leqally I do not feel I should have to be responsible for the ticket 8�tow fee. Citation#888755028.
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 WILL ATOT be returned and b�come the property of the City. Yoa 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
O 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�amaged 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 telephone numbers: Mindy Shears, (612) 363-7562.
Were the police or law enforcement called? Yes No 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 lan�m k, tc. Pleas�be detailed a ossible. If nece s ,attach a d'a am.
I was parkec�on�he east side o�SRaymond A��enue, between IVi�yrtl�Avenue& �1�ivers� venue
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to our satisfaction. I am looking for a refund of the$287.50 tow&ticket fee plus$75 due fo a half day lost at work.
�is would be total compensation of 362.50.
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make Ford Model Escort
License Plate Number HUV 139 State N� Color �ite
Registered Owner Zachary Sauvageau
Driver of Vehicle Zachary Sauvageau
Area Damaged N/A
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complet�this sectien--- _ ----_- �-eheelt�ox i€ti�is secticm does nat a�plv
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
CdCheck here if you are attaching more pages to this claim form. Number of addiNonal pages Z. ,
By signing this form,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 4/24/2013
Print the Name of the Person who Completed t ' m: a auvageau
Signature of Person Making the Clai .
Revised February 2011
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 95 FORD License#: HUV139 CN: 13027844 Invoice#: 18375
DatelTime Released: 02/11/2013 16:41 Tow Charge: $ 123.95
Released to:TOTO Storage Charge: $ 15.00
Paid by: CREDIT CARD Admin Charge: $ 80.00 \
� \�
Released by: ELISE Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234•50 �
I will check the vehicle for damage or any other problems that
may have occuRed while this vehicle was in the c�stody 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 andlor other problem:
Police Report made:Yes_No_IF Yes, CN , If NO,Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature �
Jf ►iRll 1TW1'O Lo�r
B30 BARC£CfMINNEL RD
SAINT PAUL� MN. 55107-2950
651-266-5642
1lerchai}t ID: b0N6380144
Ter� ID: 001734000J8f10638019406
Sale
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Inv�; 060003 A�r Code: 8166�5
I�rud: Online
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St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 02/11/2013 16:41 Invoice #: 18375
Vehicle Piate: HUV139/ND �
Payor: OWNER Location Paid: Impound Snow Lot
Citation:
Amount:
888755028 $ 53.00
Total Amount Paid: $ 53.00
Paid by: CREDIT CARD
KEEP THIS COPI'' FOR YOUR RECORDS
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