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Johannsen NOTICE OF CLAIM Ir'ORM to the City of Saint Paul, Minnesota Minr�esotri State Stnnr�e 466.05 sin�es tliat "...everv person...whn clninrs danxi�es.from nny municipnliry...shull cnuse�o be presen�ed to�he ��ot�erning body of tlre municipality mithi�i l80 duys after the alleged loss or inji�ry is discovered a notice stati�rg tlie time,place,nnc! circumstarrces tlaereof,nnd the anrount of co�npensation or other relief denrnnded." I'lease complete this form in its entirety by clearly typing or printing your answer to each question. If more s�ace 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 f'orm is received. The process can take up to ten weeks or longer depending on the nature of your daim. 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,��Vt-i�( Middle Initial �Last Name J � ���'��� �� �EIVED Company or Business Name Are You an Insurance Com �n Ye /No If Yes, Claim Number? DEC 16 2013 P� Y� Street Address ��i �%' �� �� � d�e� /��` Y�� �L�• �J. �I1'Y �LERK City � � "���\ State ��1,�•- Zip Code ��5��� y Daytime Phone (�) :�'C ����S�ell Phone ( ) - Evening Telephone ( ) - Date of Accidentl Injury or Date Discovered f���'S��c�/3 Time �'( 3�a�rn 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 employe s are inyolved and/or responsible for yoy�r damages. r �., �;.vC C,� , � -f/�.�' ' ��L w c:S �e�✓��� .1 �:,� �zv l�4 ✓�,:� G�-� w; ��'�iCGKI tvt.. e � 5^� �ct�' . /' �' J �.t � 't; ' f� -�� "1 � � �Gt � C�.� G I ' � � / � � O' , � „ . S.. � . Q� c� . , � /�t' �./�' ir �� t,>��.5 c v� ' '� c� L i Cv c� , �4�'f C � �' c't l5 ` i �� c�G"�d G.C�� 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 y^�� nPPd to include copies of all annlicable doeuments. 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 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 rep�irs Fl 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 d{�maged 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—nlease comnlete 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? Case#or report# 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. f,�'�>���,�r��/S t i✓t���.�-( �� � T.,,, l, Fr «e c�h,.��E ;�.-. Please indicate the amou t ou are seel:ing in compensation or what you would like the City to do to resolve this claim to your satisfaction. � � 1�1 � `v Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year Q � Make � G' � � Model A Z �.�' � License Plate Number 7,��{L�,�L State��J Color �/�.��� Registered Owner_,��,7C�Gil�l�iUc'c.��%f c?c�f�22T ��� Driver of Vehicle j���,.���� S�6?u�� i� Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—alease comulete this section 19 ct�eck box if this tiection does not�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 �(;heck here if you are attaching more pages to this claim form. Number of additional pages By signing tliis form,yoie are stating that ull 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 resiclt in prosecution. Date f'orm was completed �� ��6 6,� � � Print the Name of the Person who Completed this Form: _�C'!'� (f�J c% �GZv�,��v� , , Signature of Person Making the Claim: Revised Februatry 201 I ..... . .,. ;�;. _ � _ CITATION State of Minnesota��.,.,,�,, City of �_, # �,�F � Ramsey District Court �.� . � Citation# (lll 1 ' �, �II�III�IIIIII�IIIHII �II I I I�I I I I�I I I I�I�I _ 11�1111�11111 620900173964 s20900173964 - DL Number State Name ❑MN ❑CDL First Middle Last Address—Street,Apt# City State Zip DOB(mMdd/yyyy) Eyes Height Wei ht 9 Sex Race Ethnicity ��hicl��icen�N : Pl�tg Year �t��e� Make r M1♦ Type � Model Color !4 �� s c..,� D�te of Otfense, Ti e o Offense : � -�`°`�"� `'� t:' ;,; f J:>�f� �iµ � OAcadent/CrasFi Parking Meter•Number3 Neighborhood Code� ❑Housin�In�ury ❑Fatal ❑Pedeyyrian g/Building Code � � ❑Booked :,,.D Park/Operate ❑Owner � ; ❑Passenger ❑Driver � Offense Location��' �� �~� Q i No 1 Offense �W�� � �r�j a �#� ,R � O ` t`;y � ' -+ stann orclinanc� y � - ;p--.. ..�.. , `� ;� r , � ! No 2 Offense • ��� '=� � j siatute/ominarice No 3 Offense � Statute/Ordinance i ❑Speed 169.14(subd ): mph zone � ❑No Seat Belt Use 169.686.1(a) ❑No Proof of Insurance 169.791(2) ' AC Taken—AC: Test type: ❑ Refused ❑ Breath ❑ Blood ❑Hazardous Material DO ❑ Urine ( � ❑Unsafe Conditions ❑School Zone ❑Endangering L'rfe& Properiy ❑Wo�Zone ❑Commercial Veh. DOT# Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other ' See back of citation for information on a in p y g your fine. If cited for No Proof of Insurance or No Driver's License in Possession,Proof of Insurance and/or Driver's License must be shown at one of the Violations Bureau locations listed on the back of this citation wfthin 21 days from the date the citation is filed with the Court. Please read the back of this citation carefully and respond. 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