Jackson (2) NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
tifinnesnra Srare Srarute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
go�•erning body of the municipality within 180 days after the ulleged 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 enNrety 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 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 TWs 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��' Middle Initial 'v� Last Name �J�k���``J Q��°�ED
Company or Business Name .��
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address �,t�') ,y�:`; .�V.''`- ,L,�v4._ � ,' �_, C\�,?c' -�r ERK
City� > � :;�=` State ^'`" Zip Code `�`�it'J
Daytime Phone( ) - Cell Phone��u��)`{'��- 3`���Evening Telephone( ) -
Date of Accident/Injury or Date Discovered ���'���� � Time ��i"�'3'I �� �m/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 employees are involved and/or responsible for your dama es. C�� �3/���
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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
�❑ y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
y 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 couies of all aaolicable 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 WII.L NOT be returned and become the property of the City. You are encouraged to keep a i
copy for yourself before submitting your claim form. i
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
�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 damaged items
O Injury claims: medical bills,receipts
�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 Ciaims—dt�se comolete this section
Were chere�icnesses to the incident? �Ye� No Unknown (circle)
Pro�-ide their names. addresses and telephone num�rs i.z'�tu% �`��''°`� `^J�`��i��'� �t"�;�f,��r`���t=.J r���. �..,r%��t�-t �'r;��
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� . �
V�"ere[he 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. t��'�`� v"���r'�-' ��''�- '�`���
�:�, ;r x��.� .n�-- =��� i
Please indicate the amount you are seeking in compensatipn or what you would like the City to do to resolve this claim
, ,>:
to your satisfaction."�'�3t`� ,`" ,u<r� -���{> ;-^,�r�,l�;:�`s���y
Vehicle Claims—please comnlete tlus section ❑check box if this section does not anblv
Your Vehicle: Year `�k�'� Make ��'`°`��w Model r^A�;�'^q
License Plate Number �`i`t ����� State '"`''' Color '��'`�
Registered Owner c...c«-��� N1 ��4�c_=;.:*'
Driver of Vehicle ��"� ^^ �.-,�4t�=x��
Area Damaged *-/�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease comnlete this section ❑check box if this section dces not avnlv
How were you injured? '�/�
What part(s}of your body were injured? ti/x�
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): �i��
Address Lj�� Telephone
Did you miss work as a result of your injury? Yes �_
When did you miss work? ='��� (provide date(s))
Name of your Employer: ��'jk
Address �i>> Telephone
❑ Check here if you are attaclung 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 proeessed.
Submitting a false claim can result in prosecution. Date form was completed l`��`�7r.�%�3
Print the Name of the Person who Completed this Fon9n• �=�tJ '", �����`''-'
�
Signature of Person Making the Claim,� �s'fL' �
Revised February 2011
i
; CITATION �
; �
' State of Minnesota Ramsey District Court �
;
; City of
i Citation# I III IIIIIIIIII(IIII IIII)IIIII IIIII IIIII IIIII IIIII IIII)IIII)IIII(II) �
II I _ �
I
62�90�2�6,4L�L�, 620900206444 i
�
� DL Number State
. ❑MN ❑CDL
{ Name i
First Middle Last i
I, Address— Street, Apt#
� City State ZiP
; DOB(mm/ddlyyyy) Eyes Height Weight Sex Race Ethnicity
I' Vehicle License No. Plate Year State Make Type Model Color
I x. ;.rt i i�_ � i�`1 n�'� ��/; , n.,,�� ' �.� . � .� �
�. . � 3
; Date of Offense Time of Offense ❑AccidenUCrash
t f q t im ❑Property ❑Injury ❑Fatal ❑Pedestrian �
Parking Meter Number . Neighborhood Code ❑ Housing/Building Code N
� � �
, ❑Booked 0"Park�Operate ❑Owner ❑Passenger ❑Driver 0 �
__ � ,
Offense Location _ J�,� N �
, '`, ,:E - � O ,
No 1 Offensern Statute/Ordinance•'' � �
1
, No 2 Offense stac�ceio�d�na��e ^ � ;
� � '
No 3 Offense Statute/Ordinance �.
! �
❑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 ❑ Urine E
, ❑Hazardous Material (DOT) ❑Unsafe Conditions ❑School Zone �
' ❑Endangering Life& Property ❑Work Zone ❑Commercial Veh. DOT# i
Identification: ❑DL ❑DVS Web ❑Photo ID ❑Other
' See back of citation for information on paying your fine. i
� 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 within 21 days from the date the citation is filed wilh the Court.
Please read the back of this citation carefully and respond. �
�
�
i
�
, Officer(s)Name(s) �
� Officer No(s). , . CN# „{ ,+ ti�.;;,: Citing Dept ,_ , �
� ' �'' _ . �
How Issued ❑In Person ❑Mailed Cl"t.eft at Scene �
i i
' � DEFENDANT �
i
Tc find out if;�o��r citaiio�is pz;able v;�thout a��saK appearar��e hov:�ucF+-��• �' ,-.
your fine,choose one of the following methods:
• C�nline: Ae���?s��,_. •._��•,;,-�e��its.sfate.mn.us
• ay Pi!one: ��'� _. -_r�-��=;=G�
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Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 05 NISSIAN License#: 499ERU CN: 13267540 Invoice#: 23846
Date/Time Released: 12/19/2013 22:01 Tow Charge: $ 123.95
Released to: TOTO � Storage Charge: $ 0.00
�.
Paid by: CREDIT CARD Admin Charge: $ 80.00
�
Released by: JENNIFER 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
Signature s�2000
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From: "City of Saint Paul°<citvofsaintpaul(a�,public.QOVdelive .r�>
Date: December 19,2013 at 10:44:41 AM CST
To: charlie.blackwell(cUgmail.com
Subject: Saint Paul Public Works continues fight against compacted snow,re-plowing all day plow routes
Reply-To: cityofsaintpaul(cLpublic.govdelivery.com
Saint Paul Public Works continues fight against compacted snow, re-plowing all day
plow routes
In order to stay in front of cold temperatures forecasted for the aftemoon and evening of
Thursday, Dec. 19, city snow crews are out in full force today, re-plowing all day plow
routes. This is not a snow emergency—rather a continued cleanup of compacted snow. To
help city crews in plowing, residents are asked to move their cars from day plow routes today–
Thursday, Dec. 19 – but it is not mandatory. Cars will not be ticketed and towed, as this is not
a snow emergency. Remember, day plow routes are any street which does not contain a
"SNOW EMERGENCY" sign.
Temperatures remained warm overnight into Thursday morning, allowing salt and sand
products to continue working. More than 60 plows are working today to re-plow residential
day plow route streets.
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