McDonald (3) NOTICE OF CLAIM FORM to the City of Saint Paul, Min�e�i�IVED
Minnesota State Statute 466.05 states that "...everyperson...who claims damages from any municipality...shall cause to be��egenl�OaRoQ,�t�IJ
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." C I TY C L E R K
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 ezpiain 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 t�10 Middle Initial_ -�-�Last Name M�(�/U f�- � � ��������
Company or Business N me �'EC Q 9 2��3
Are You an Insurance Company? Yes� If Yes, Claim Number? �.�T�LEF�K
Street Address �� � 6 �6�(o `� 7 7 c�
City�`j� ���L State /V�� . Zip Code�� /
Daytime Phone L� - Cell Phone����-���Evening Telephone�� -
Date of Accident/Injury or Date Discovered �/ Time 7�'d am%p�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 andlor responsible for your damages. �
LL_ �i'c�er � o�f�- C� N� • ' _ o � � T o�
� �7 !�� � U� � / C�c�s ei! e -� '�
� �itl e Gw .S h-�L e � /r�e i
/ � s � ,r� n e e �---,r,
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Please check the box(es)that most closely represent the reason for completing this form:
��u�'/t/ ��� -
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ 1vIy vehicle was damaged by a pothole or condinon or the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
�-6ther type of property damage—please specify M (����/�_ � (,�Q�' -Tp �P,,.J a n r�yy,h��/ G/`l �
❑ Other type of injury—please specify NLVe�
In order to process your claim you need to include copies of all applicable documents. �E-'��/�
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of '
your claim. Documents WII.,L 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
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�iamaged 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 retnrn both pages will result in delay in the handling of your claim.
All Claims-ulease comvlete this section .
Were there witnesses to the incident? Y No Unlmown (circle)
Provide their names,addresses and telephone numbers:
SDn��r'a�TvuS ��c2�—L►y�.,� /e S• �a /�L--g���-�oS"8' �
Were the police or law enforcement called? Yes No Unlrnown (circle)
If yes,what department or agency? Case#or t3 - �Y�o Q�
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.
V
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. �''u,D ��CQ���d � 't!e/1�{7�T e 1"��f .1�/a�s � �7� •o e
Vehicle Claims Qlease complete this section �check box if this section does not applv
Your Vehicle: Year�_Make C Model S- / � �c ck' 4P •
License Plate Number pf�- Ab State�n! Color i�(� _
Registered Owner
Driver of Vehicle ,a nr fl�v�T_r�aro a��► '
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this section check box if this section does not a 1
How were you injured?
; What part(s)of your body were injured?
i
I 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 in�ury? Yes No
- - -T—:-- --- - -�
- When did you miss work? — - --- - ---— --- -- -- (provide date(s))
Name of your Employer:
Address Telephone
I
�Check here if you are attaching more pages to this claim form. Number of additional pages�.
at all in ormation ou have rovided is true and correct to the best
i nin this orm ou are statin th p
B.v S g g .f ,.v g 1' .v
� 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: /�j/�L{►aN�S/ P, /�eaatl'f!-��
Signature of Person Making the Claim:�lJ� �/�'�XII �'
Revised February 2011
s -----
11/13�2013 20:43 Property and Cash Reqister Page 1 of 1
Name: MCDONALD,ANTHONY PIERRE Booking No.:201300018354 Ident Number:
PROPERTY TRANSACTIONS Property Number: 40
Item Number Descriotion/Color
SHIRT 1 GRAY
PANTS 1 BLACK �
SHORTS 1 GRAY l�
SHOES 1 BLACK �
BELT 1 BROWN '��
!:j�`.
HAT 1 BLACK f'
MISC PAPERWORK � , ` {r'�'
PHONE 1 SAMSUNG ,•''� � j
NECKLAC',E 1 P!NK �� �
JACKET 1 BLUE '`�f
JACKET 1 BROWN �
JACKET 1 BLUE
CASH TRANSACTIONS
Transaction Description Date Amount Officer
7 INITIA�DEPOSIT 11/13/2013 .00 mahert
The items listed in this form were taken from me. ��/�� N�J`� ��t`�r� / .
Z�r
Inmate Signature�����j�/• ��./��,���
De ut Si nature �; ��
P Y 9 CzNuiy.�yi�a�ure
Badge# Badge#
I acknowledge this notification that my outgoing telephone calls, except to my attorney,
are subject to monitoring and recording. I understand it is my responsibility to inform the
Sheriffs Office of my attomey's telephone number. �� Initials:
By signing this, you acknowledge that you will be charged a $3.00 deposit for the use o` a vending
card while in custody. This $3.00 deposit will be refiunded upon the return of the vending card at the
time of your release from this facility. The $3.00 dAposit will not be refunded, if the vending card is
damaged or lost.
initialS:
Pursuant to Minnesota Statute 64�.12, subd.1 the Ramsey County Board of Commissioners
has authorized the Ramsey County Sheriff's �epartment fo collect a $25.00 booking fee from
inmates placed in custody at the Ramsey Co��nty Adult Detention Center.
I acknowledge that $25.00 booking fee will be deducted from my account.
Inmate Signature: Refused:
Officer Signature:
�aint Paul Police Imp�und �ot, 830 Barge Channel R�ad, Vehicle RelEase IForm
Make: 95 CHEVROLET License#: 358KAB Ci�l: 13244601 Invoice#� 147586
Date/Time Released: 11/14/2013 16:06 Tow Charge: $ 54.5Q
Released to: OWNER Storage Charge: $ 15.00
Paid by: CASH Admin Charge: � 80.OQ
Released by: PERLITA Tax: (7.625%j � 10.2F
I,the underslgned,have �ecavered the vehicle descr,heq above. Subtotal� � 159.76
I will check the vehicle for damage or any ether proolems that
m„�y have eccurred whife this vehicle was in the custody of the Service Cr�arge: � Q.00
Samt Paui Poiice Depa;tment. I acknewledge I w;l, �e;aort -
damage and/or any other problems to the Impound Lot stafif To±al Charges: $ 159.76
on this form prior to leaving the impound Ict.
Damage and/or other problem: � � ���U�r � --�l�fl.i
r '�
���I C�=f� '��'�� i'�✓l�` �-
Police Report made: Yes 1/No_IF Yes, CN , If NO, Why?
TO PROTECT:YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
/ )
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Mir,nesota 5rai� S��;;,;� 46�.05 /�IOTICc OF CLA�IlIi1...lE)very person... �,vho c/ain�s damages f�om any
r..�ur,ic;palrt;�...sh�;! ��us� :� be p�esent�d ro t,';e goveming body of the municipa/ity �vi7hin 180 days a;ter the �
�l.'eged loss �r ;�rj��r�,; ::; �isccve,�ed a notice �rating rhe rtim�, place, and cireumstances thereof, and the amount of
compens=rien cr c�:^�er relief demanded. �
pI23S2 complete t(�is forr.� i:; i,s enfire�y by ty�i�g or printing your ans�n�er to each q�:e��ion i�
t{�e spaee pE�ovided. If additional spacE i5 needed, p(ease aftach additiona( sheets.
_ - ���=asF ��TUK�U -rhE� c:�f��� of c�t�� ��z;c: RECEIVED
- C0,1�'!PLETED FORf1" T0: 170 City Hall
15 W I{ellogg Bivd NOV 19 2013�
St Paul MIV 55102 CITY CLEf�I�
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Date of Accider�z or ir�cident; � �3 � � Day or' `�1✓eel;: � �� _ Time: � am or�(circie onel
Flease s�a�c, in deiail, wl,,at cccurred ana ine circumstances surrounding the event. Indicate how the
�ity of Saint P�ul is invclved, and why you teel tf:e City is responsible. '
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rl�ase indicate your r��scn for completing this f�rm:
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�-' eliicle accident � �
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❑ Vehicle damaged ` � " �ther injury to person (please provide specifics below) `�
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Saint Paul Police Department Page , ofz
PUBLIC
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference C.N. Date and Time of Report
13244601 11/13/2013 19:56:00
Primary offense
DWI-DWI OVER .10
Primary Reporting Officer: MCdOt121d, Darin Name of location/business:
Primary squad: 162 Location ofincident: FORD PA&WOODLAWN
ST PAUL, MN 55116
Secondary reporting officer:
District: Western Date&time ofoccurrence: 11/13/2013 19:09:00 to 11/13/2013 19:09:00
Site:
Secondary otfense: LIQUOR LAW-OPEN BOTTLE IN AUTO Arrest made? Yes
OBSTRUCTING-OBSTRUCTING LEGAL
PROCESS
OPERATIONS
Pursuit engaged Resistance encountered YeS
Weapons Used by Police Weapons Used by Suspect at Time of Arrest
ARRESTS
Name Mcdonald, Anthony Pierre Date 8 time ofarrest: 11/13/2013 19:09
eooking date 11/13/2013 Arrest Status Booked
eooking time �g:59 Arrest made on view: Y2S
Booking# Arrest made on warrant or previous CN:
Warrant number Originating agency
NAMES
Arrestee Mcdonald, Anthony Pierre
KNOWN
ST PAUL MN 55102
Other Glubranson, Lucas Michael
ST PAUL MN 55116
PUBLIC NARRATIVE
On 11/13/13 at 1905 hours, SQD 162 while on routine patrol stopped MN TAG 358KA6 at Ford Parkway/
Woodlawn Avenue for equipment violation (cracked windshield) and expired registration (08/2013). SQD
approached the driver's side of the blue 1995 Chevrolet S10 pickup and observed two open beer cans between
the driver and passenger. SQD observed the driver had bloodshot and watery eyes and was evasive during
questioning. SQD identified the male as MCDONALD, ANTHONY PIERRE 56 yo.. MCDONALD stated he had
consumed several alcoholic beverages. SQD removed MCDONALD from the vehicle and MCDONALD
refused to comply with officers commands and was brought to the ground and was handcuffed. Failed PBT at
the scene. SQD transported MCDONALD to the LEC where he was read the Motor Vehicle Implied Consent
Advisory Form and submitted to DMT-G breath test. MCDONALD's test result was .10
AC.BOOKED:MCDONALD, ANTHONY PIERRE 56 yo 895 Randolph Avenue #3, Saint Paul, MN 551024th
Degree DWI/ M/ 6209001856800LP/ M/ 6209001856800pen Alcoholic Container in MV/ M/620900185680
Warrant type (none) Charge/CitatioN8ai1 Amount OLP/620900185680
Open Bottle(Alcoholic Beverage)in MV/
Saint Paul Police Department Page 2 of2
PUBLIC
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference C.N. Date and Time of Report
13244601 11/13/2013 19:56:00
Primary offense
DWI-DWI OVER .10
4th Degree DWI/620900185680
i
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