APPLICATION FORM FOR PAYMENT OF CLAIM AGAINST THE CITY OF SAINT JOHN
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1 APPLICATION FORM FOR PAYMENT OF CLAIM AGAINST THE CITY OF SAINT JOHN For office use only Claim File No. Approved by Date Cheque No. Issued on Claim not approved Date Reason for not approving claim The claimant is applying for compensation for the issuance of a Parking Violation ticket and/or towing related charges as a result of the declaration of a snow ban for January 23, Name of claimant (Please print your name) Other (Please print name) A TYPE OF NOTIFICATION The claimant relied on the following notification system(s) during the weekend of January 23, 2011 in order to determine if a snow ban had been declared (please check each applicable): My Saint John Alerts Snow Bans Official website of The City of Saint John Ce formulaire est disponible en français Page of 6
2 Parking brochure entitled Parking in the South/Central Peninsula What you need to know? Snow ban alerts by text message on cell phone B GENERAL INFORMATION OF CLAIMANT Please proceed to Section B. Mr. Mrs. Ms. Miss Other (Please specify) Family name Home address (e.g., Street, City) Given name(s) Mailing address (If different) Province Postal Code Province Postal Code Home Telephone No. (Include area code) Business or Alternate No. (Include area code) Address registered with My Saint John as of January 23, 2011 Username registered with My Saint John as of January 23, 2011 Text Message Address registered with My Saint John as of January 23, 2011 Vehicle Plate Number Make of Vehicle Series (e.g. Cavalier, Focus, Laredo, Camry etc ) Model (e.g. 2 Doors or 4 Doors) Ce formulaire est disponible en français Page of 6
3 Amount of Claim (Please specify items which are being claimed) Name of Registered Owner of Vehicle Home Address of Registered Owner (e.g., Street, City, Province, Postal Code) Home Telephone No. of Registered Owner (Include area code) 1. Parking Violation ticket $ 2. Towing Related Charges $ Total $ Specific reason for claim Supporting Documentation (Please list) C DECLARATION Please proceed to Section C. 1. I UNDERSTAND that the personal information provided on this application form is collected for the purpose of determining the claimant s eligibility for the reimbursement of a Parking Violation ticket and/or towing related charges resulting from the declaration of the snow ban on January 23, Ce formulaire est disponible en français Page of 6
4 2. I UNDERSTAND that participation in this reimbursement is voluntary. Failure to complete any part of this application form or submitting an incomplete application form shall result in the claimant s claim being rejected. 3. I UNDERSTAND that it is against the law for anyone to knowingly make a false or misleading statement on this application form. 4. I DECLARE (please check each applicable): A. That subsequent to the 26 th day of July, 2010 and prior to 11:16 a.m. on the 23 rd day of January, 2011, I registered (or re-registered) my address at My Saint John on The City of Saint John official website in order to obtain alerts regarding snow bans. B. That my address referred to in paragraph A was still active on the 23 rd day of January, C. That I relied upon the official website of The City of Saint John in order to determine if a temporary overnight parking ban was declared on the evening after the snow storm of January 21, D. That I relied upon the parking brochure entitled Parking in the South/Central Peninsula What you need to know? in order to determine if a temporary overnight parking ban was declared on the evening after the snow storm of January 21, E. That subsequent to the 26 th day of July, 2010 and prior to 11:16 a.m. on the 23 rd day of January, 2011, I registered my text message address at My Saint John on The City of Saint John official website in order to obtain text message alerts on my cell phone regarding snow bans. F. That my text message address referred to in paragraph E was still active on the 23 rd day of January, I DECLARE that I paid a fine amount for the Parking Violation ticket (please check one) within 7 days: $20.00 within 8-30 days: $30.00 after 30 days: $50.00 Ce formulaire est disponible en français Page of 6
5 6. I DECLARE that I had paid $ (please write amount paid) to a towing company in order to receive my vehicle. 7. I CERTIFY that the information I have furnished on this application form is true and correct. 8. I UNDERSTAND that when I sign this application form, it is the same as taking an oath. Claimant s Signature Date (yyyy-mm-dd) Send completed application form on or before April 22, 2011 at 4:30 p.m. by mail or personal delivery to: Saint John Parking Commission City Hall Building 11 th Floor 15 Market Square P. O. Box 1971 Saint John, New Brunswick E2L 4L1 For questions, call (506) (Leah Fitzgerald). communications@saintjohn.ca Attention: Office of the Saint John Parking Commission Use this application form to file a claim against The City of Saint John for the following reasons: You incurred expenses following the snow ban declaration for January 23, 2011 by having your vehicle ticketed and/or towed. You are eligible to receive your claim because you were registered prior to January 23, 2011 to receive alerts for snow bans; or relied upon the official website of The City of Saint John; or relied upon the parking brochure entitled Parking in the South/Central Peninsula What you need to know? ; or relied upon the snow ban alerts by text message on your cell phone. Your claim has been submitted prior to the expiration date of Friday, April 22, 2011 at 4:30 p.m. Ce formulaire est disponible en français Page of 6
6 INSTRUCTIONS FOR COMPLETING THE APPLICATION FORM FOR PAYMENT CLAIM AGAINST THE CITY OF SAINT JOHN 1. All application forms must be submitted to the office of the Saint John Parking Commission, 11 th Floor, City Hall Building, on or before April 22, 2011 at 4:30 p.m. 2. The appropriate notification box has been checked in Section A. 3. Section B has been properly filled out. 4. Application form MUST contain the following supporting documentation: A copy of the Parking Violation ticket issued on January 23, 2011 or January 24, 2011 pursuant to the Saint John Traffic By-law; A copy of the receipt showing that the Parking Violation ticket has been fully paid; A copy of the receipt from the towing company showing amount paid for towing charge; and A copy of the most recent vehicle registration. 5. Section C has been properly filled out, signed and dated. Ce formulaire est disponible en français Page of 6
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