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Bouchard, Tania & Carol Minnesota State Statute 466.05 states that"...every person...who clnims damages from any municipality...shall cause to be presented to the governing body of the municipatity within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and tFte amount of compensation or other relief demanded." Pieaise compiete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. P1eas�e note that you will not be contacted by tetephone to clarify answers,so provide as much iuformation as necessary to explain your claim,and the amount of compensation being requested. Yon 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 17�is form must be signed,and both pages completed. If something dces not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY C��E I VE D 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,�v sslo,�� Og Zp13 �i_ � � �� rc� c�iTY First Name�r!(7 ��l Middle Initial Last Name C L E RK Company or Business Name Are You an Insurance Company? Yes No If Yes,Claim Number? I Street Address q'C'�G> � I�/�,�1 Q �1�`j. �`U� t� City `�- ��(.l'f State�V l J�1 Zip Code__i�v�� I� Daytime Phone��CeII Phone( ) - Evening Telephone(_) - � Date of Accidend Injury or Date Discovered �� ' ��' �� Time am/�, �(G��y�1� � Please state,in detail,what occurr�d(happened),and why you ate submitdng a claun.Please indicate why or how you ; feel the City of Saint Paul or its employees are involved and/or responsible for your damages. � � r i�U ,�',�1 , ��hc��s �► c.�.) CL9✓1 t�lX'.� � t�w� ,f � 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 '��Iy vehicle was wrongfully towed and/or ricketed ❑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 cooies of all apulicable documents. For the clairns types listed below,pleas�be sure to inclut�e the documents indicated or it will delay the handling of I your claim. Documents WII,L NOT 1�returned and become the property of the City. You are encouraged to keep a I copy for yourself before submitting your claim form. ! O Property damage claims to a vehicle:two esthmates 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 dannage claims: two repair estimates if the damage exceeds$500.00;or the actual bills aad/or receipts for the repairs;detailed list of damaged items �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 retarn both pages of Claim Form 4 � , � N � � � �"' ti O �' J ' � V rn O � � �c) O �n � , � C � � � � N � N Z � EA EA Efl EA EA ff� (f� Q � � W J � � W ' � N � � � o � � Q' t � U � N . . U � � � � � � V co � � � � W ; � � V � c � o � U � w . i" � X � � � . � a°°o F- c� Q F- c� c� F- Z Q ± O c.i � � , � N Q . � N +r N 0 � � . � V N (n � � (�U � cn W � � � T o J . V a� � a �o m � � N L � � � X c� o � = � � � � m �n Q � 3 � a � L v � � � — o Z >- � ca pp � a> .� � a� n U Q � � , _ °' E •� v o . -a o vi oMO u�i v > c�p � � � c r � c 1 � O � � O � � C N � i C � � a ,, . . � O U � � � U U N 'Q- W � J J N '� �L � � � I � \� � O � � ; — Q �� Z � r �.a � N o � tn � O +� � _ � o � y � � � a� ` E �.� o '� v� � ; � L o a� � a> > � � � � � 3 QY � fl- � � �, , � a_°i O U W � � � p �"° ,�.�., a p � , U Q t '— . • � � � � � � a� � a� cv � o ca � �, � � Z � Q J �J > L U � .� L- E � � � ~ � W �+�.. U � O � � � V :. � 01 � � O � T � p a, 'a � O W � � � � U � � N > td � � N N H � , a dj � N � (Nd � U L a �� N � d C , Y � N 'a N N = >, C � �-. � �- � (� � o � a � `= 3 � u� a o o a° � v� Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please com�lete this section ��,� Were there witnesses to the incident? Yes �No Unlrnown (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? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmazk,etc. Please be as detailed as possible. If necessary,attach a diagram. Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. , Vehicle Claims— lease com lete this secti n check box if this section does not a 1 Your Vehicle: Yeaz Q�Make V Model `i License Plate Number State C lor ' Registered Owner C � � Driver of Vehicle � Area Damaged � � �� City Vehicle: Year �Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injurv Claims—alease complete this sec�on ��/��D > ❑check box if this section does not anvlv 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 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 Print the Name of the Person who Completed this Form: /�� lnl ��i.d�Lf Signature of Person Making the Claun: ��'�1i1 j0 �A�c l'�t 1CQ Revised February 2011 Citation# g g g 7 4 3 8 3 g ST. PAUL STATE OF WIINNESOTA-RAMSEY DISTRICT COURT � l l(` ��!�� `�� !��`�� 7he u�dersigned,being duly sworn,upon hisRier oath deposes and says: �� !I�I� I�I��I� I� I� I �1 I � * 8 8 8 7 4 3 8 3 9 * Date of Otfense t� �� 12- Time of Offense � � '� t �t_�A C Plate 11 N dr Color C�f v Veh.License No. 10 �0 Year J Stat� Make Style LQCalion oi Offense: w � - ��'�^'��A� �� ry��""" Y�`��,p`�� VIOLATION: � SNOW EMERGENCY St. Paul Ordinance 76i.03 FINE $53.0� (Amount includes mandatory state aurcherges of 513.00) CN 1�'Z C( � Citing �` �� Otlicer �� Citing ��1 pfficer Number Dept. �sted Night Pbw ❑Day Plow O Plowed in(Wind�ow) [�gged Befora Plow ❑Orove OH OFFlCER'S NOTES p[VO PLATE VIN: Citatlon can be peld at the Impound Lot.Plsase read the back of tha eltstlon fa paymsnt Fnst►uctions. COMPIAINT r I I �� L � ✓ �� -�� I � � -� �� "y'1� � �� , , � � V�� '��1.� 1� � �� 1 t 1 % j V 1 i I , '�. � � ; NOTICE OF CLAIM FORM to the City of Saint Paul, 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 cleariy 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 dces 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��/'t�� Middle Initial� Last Name� ^ 1'� �� Company or Business Name Are You an Insurance Company? Yes �To If Yes,Claim Number? Street Address C C � City State �t'1 Zip Code� Daytime Phone�)L.� ��1 Phone( ) - Evening Telephone( ) - Date of AccidenU Injury or Date Discovered ��`�� o� Time am/pm ��K1 �Z�� 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. � �� ' � � f3Z�l i � �� l - 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 ��Iy 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 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 befare submitting your claim form. O Property damage claims to a vehicle: two es imates for the repairs to your vehicle if the damage exceeds $500.00;ar the actual bills and/or receipts for t�e repairs O Towing claims: legible copies of any ticket lssued 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 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—ulease comnlete this section � Were there witnesses to the incident? Yes No C�.,`�3u1;n�wr� (circle) Provide their names,addresses and telephone numbers: �" �._. Were the police or law enforcement called? Yes No nknown (circle) If yes,what department or agency? Case#or repo 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. 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. Vehicle Claims— lease com lete this s tion ❑ che k box if this section does not a 1 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 Name) Area Damaged Iniurv Claims please complete this section ❑ check box if this section does not apvlv How were you injured? What part(s)of your body were injured? �, Have you sought medical treatment?�\ y� Yes No Planning to Seek Treatment(circle) When did you receive treatment?�"T,�Yi" (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? N/� 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 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 �'S — �� ,�� , . Print the Name of the Person who Completed this Form: t ��L�� --��-j£��v�� Signature of Person Making the Claim: `� �� "�-r - Revised February 2011 ��tat�on� $g$ 7 L� 3 g 4 0 ST. PAUL STATE OF MI�NNESOT duR swornY DISTR��Coa hRde oses and sa s: I��ill�Ifl�)��III IIIII��)I{II��I�I IIIII lII�I l��I 11�� The unders�g ed, be ng y , po p Y * 8 8 8 7 4 3 8 4 0 * Date af Offense t�� /�� Time of Offsnse l�2 ' 62 12L+ ` � Plate1'L ��Vy��, S�1e �V Color S^1Vr Veh.l.icense No. 1 J l J� Year J State �N Make LocaGon oi Oftense: w �5 ' � YlOLATION: � SNOW fMERGENCY St. Paul Ordlnance 161.03 FINE $53.�0 (Amounf includes mandatory state surd�ges of$13.00) CN ,�F�ti i Citing y�,� f� � Citin Offioer_�1-�`�"�'�'� Nu ber �v Deptg. — �sted Night Plow ❑Day Plow O Plowed in�rxirow) �agged Befo�e Plow ❑Drove Off OFFICER'S NOTES �NO PLATE VIN; Cttation can be peid at the Impound Lot.Pleese read the back of ihe cftatMn for psy+nsnt instructions. COMPLAI NT DEPARTMENT OF PUBLIC WORKS Rich Lallier,Director CITY OF SAINT PALTL Kevin Nelson,P.E.Street Maintenance Engineer Christopher B. Coleman,�fayor 873 North Dale Street Telephone: 651-266-9'00 Saint Parsl. M.�' S5103 Facsimile: 651-266-9'36 *n�r�u� c��.��,�,��. December 14,2012 Tania Bouchard �ichael Blood _ _ 995 W. Minnehaha Avenue Saint Paul, Minnesota 55104 Re: Vehicle License #646GAC This letter is to express our sincere apology for the inconvenience caused during the recent snow emergency where you were towed and/or ticketed. The Department of Public Works needed to make snow emergency plow route changes in your area due to the light rail construction. Due to a gap in notification,you were not aware of these changes when we declared the December 9th snaw emergency. For this snow event, due ta the lack of communication regarding these route changes,the ticket will be forgiven and any towing and impound lot fees will be refunded to you. Please contact us at 651-266-980Q to arrange for reimbursement. For all future snow emergencies, you should note that the day plow/night plow rules will be followed and no additional allowances will be made to ticket fees and/or towing charges. A ain,please accept our apology for the inconvenience this has caused during this snow emergency. g Sincerely, �� , �� Kevin Nelson Street 1vlaintenance Manager ��s�,� � 4Q . O `, "��: An A�rmative Actian Egiral Opportuniry Employer ^ SAINT PAUL > s n�cvcaacs� "ai.. �oi '�.�.. ....r . Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 02 TOYOTA License#� 606GAC CN: 12288997 Invoice#: 17922 Date/Time Released: 12/10/2012 15:25 Tow Charge: $ 123.95 Released to: TOTO Storage Charge: $ 0.00 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: $ 219.50 I will check the vehicle for damage or any other problems that may have occurred 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: $ 219.50 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 PROBLEMS/DAMAGE BEFORE LEAVING THE LOT I Signature T� t� �� .u---� _ 5i2000 li